Knee Arthroplasty Research Articles

Chronic post-surgical pain after total knee arthroplasty: a narrative review.

Total knee arthroplasty (TKA) is an efficacious treatment for end-stage knee osteoarthritis, often accompanied by severe postoperative pain. In certain patients, this pain can persist for over 3months and is referred to as chronic post-surgical pain (CPSP). Postoperative persistent pain has emerged as a significant and noteworthy issue impacting patient quality of life following TKA. The etiology of CPSP after TKA is multifaceted. Peripheral or central sensitizations resulting from inflammatory reactions, nerve injury, and neurobiological mechanisms are the primary mechanisms contributing to chronic persistent pain after TKA. Preoperative, intraoperative, and postoperative factors can induce pain sensitization. Once CPSP occurs after TKA, it significantly hampers patient recovery with challenging treatment options. Currently, among the preventive and therapeutic strategies for chronic pain after TKA, it is widely believed that early comprehensive preventive treatment to prevent acute to chronic pain transition can substantially reduce the incidence of CPSP following TKA. In recent years, studies have investigated perioperative strategies aimed at reducing the occurrence of persistent pain after TKA. This article provides an overview of advancements in understanding the pathogenesis, high-risk factors, and preventive measures for chronic pain following TKA. We hope that this review will guide future research directions on CPSP after TKA while contributing to clinical perioperative pain management.

Day-case success or why still in hospital after total hip, total knee, and medial unicompartmental knee arthroplasties?

Day-case success rates after primary total hip arthroplasty (THA), total knee arthroplasty (TKA), and medial unicompartmental knee arthroplasty (mUKA) may vary, and detailed data are needed on causes of not being discharged. The aim of this study was to analyze the association between surgical procedure type and successful day-case surgery, and to analyze causes of not being discharged on the day of surgery when eligible and scheduled for day-case THA, TKA, and mUKA. A multicentre, prospective consecutive cohort study was carried out from September 2022 to August 2023. Patients were screened for day-case eligibility using well defined inclusion and exclusion criteria, and discharged when fulfilling predetermined discharge criteria. Day-case eligible patients were scheduled for surgery with intended start of surgery before 1.00 pm. Of 6,142 primary hip and knee arthroplasties, eligibility rates for day-case surgery were 34% for THA (95% CI 32% to 36%), 34% for TKA (95% CI 32% to 36%), and 52% for mUKA (95% CI 49% to 55%). Surgery before 1.00 pm was achieved in 85% of eligible patients. The day-case success rate among patients with surgery before 1.00 pm was 59% (95% CI 55% to 62%) for THA, 61% (95% CI 57% to 65%) for TKA, and 72% (95% CI 68% to 76%) for mUKA. Overall day-case success rates (eligible and non-eligible) were 19% (95% CI 17% to 20%) for THA, 20% (95% CI 18% to 21%) for TKA, and 42% (95% CI 39% to 45%) for mUKA. Adjusted analysis confirmed higher day-case success in eligible mUKA patients (odds ratio 1.9 (1.6 to 2.3)) compared to TKA and THA patients. Primary causes for day-case failure were mobilization issues (9% to 12% between procedures), prolonged spinal anaesthesia (4% to 9%), and postoperative nausea and vomiting (PONV) (4% to 14%). THA and TKA patients showed comparable eligibility (34%) with similar day-case success rates (59 to 61%), whereas mUKA patients demonstrated higher eligibility (52%) and day-case success (72%). Mobilization issues, prolonged spinal anaesthesia, and PONV were the most frequent causes for not being discharged.

Complications of total knee arthroplasty in patients with prior anterior cruciate ligament reconstruction compared to a matched cohort

BackgroundCurrent literature reports a 500 % increase in reoperation in total knee arthroplasty (TKA) after anterior cruciate ligament reconstruction (ACLR). The purpose of this study is to determine the effect of ACLR on subsequent TKA. MethodsThis retrospective case control study included 30 patients that underwent TKA following an ACLR who were matched 3:1 to a control cohort at a single tertiary academic center between January 1, 2011 and January 1, 2021. The electronic medical records were queried for demographics, complications, history of ACLR, and range of motion (ROM) preoperatively and postoperatively at 3 months and 1 year. Student's t-tests and Fisher's exact tests were used for analysis (α = 0.05). ResultsThe mean ROM between the ACLR and control groups preoperatively, at 3 months and at 1 year postoperatively were 108.2° v 104.8° (p = 0.42), 114.0° v 111.8° (p = 0.51), and 115.3° v 115.8° (p = 0.88). At 1 year, 9 of 30 (30 %) ACLR patients decreased ROM versus 14 of 90 (15.6 %) control patients (mean loss of 21.4° v 11.9°, p = 0.076). No difference in complication rate was found (10 % v 11.1 %, p = 1). Complications in the ACLR group included open debridement and capsular release for stiffness after 2 failed manipulations under anesthesia (MUA), lysis of adhesions for patellar clunk, and revision surgery for flexion instability. No control patients required MUA. ConclusionThis study demonstrated that TKA following ACLR is without an increased risk of complications. However, ACLR patients should be followed closely since loss of ROM can be large.

Delirium risk profiles in a population-based study of United States older adults undergoing common noncardiac surgeries.

Older adults often require surgical care and are at elevated risk of delirium. We explored delirium risk profiles across the population of U.S. older adults who underwent one of 10 common noncardiac surgeries. We analyzed Health and Retirement Study (HRS) participants linked with Medicare billing data who underwent the following 10 noncardiac surgeries from 2000 to 2018 at age 65 or more: total knee arthroplasty (TKA), total hip arthroplasty (THA), spine surgery, cholecystectomy, colorectal surgery, hernia repair (ventral, umbilical, or incisional), endarterectomy, prostatectomy, transurethral resection of the prostate (TURP), and hysterectomy. Demographic and health covariates were obtained from the HRS dataset. Latent cognitive ability was calculated from cognitive testing, proxy reports, and demographics at the preoperative HRS interview. We compared standardized differences for delirium risk factors across the 10 surgeries and qualitatively clustered them into phenotypical subgroups. We analyzed 7424 older adults (mean age 76 ± 6 years, 45% male). Endarterectomy patients presented with the highest burden of nearly all health and cognitive factors, implying higher delirium risk (e.g., stroke, 22%; depressive symptoms, 30%; high school or less education, 73%; frailty, 42%; lowest latent cognitive ability). A second "general surgery" phenotype, including cholecystectomy, colorectal, and hernia surgery patients, experienced more frailty (29%-32%) and depressive symptoms (24%-26%), with moderate comorbidity burden. A third "pain" phenotype, which included TKA, THA, and spine surgery patients, commonly reported moderate or severe pain (47%-53%) and impairment in activities of daily living (ADL, 23%-30%), but fewer comorbid medical conditions. The remaining surgery types (hysterectomy, prostatectomy, TURP) were not phenotypically grouped and generally had lower risk features for delirium. In an epidemiological cohort of US older adults, we identified clinically meaningful heterogeneity in delirium risk profiles across different surgical types, which may have implications for delirium risk stratification and delirium prevention or treatment.

Effect of posterior-stabilized and cruciate-retaining implants on three-dimensional kinematic characteristics after total knee arthroplasty

Effect of posterior-stabilized and cruciate-retaining implants on three-dimensional kinematic characteristics after total knee arthroplasty

Patient‐reported outcome measures following individualised TKA are not affected by the degree of preoperative coronal varus or valgus laxity

AbstractPurposeTo determine whether there is a correlation between preoperative coronal varus or valgus laxity and patient‐reported outcome measures (PROMs) 2 years after individualised total knee arthroplasty (TKA).MethodsRecords of 150 consecutive patients who received individualised TKA were retrospectively analysed, and 126 with complete pre‐ and postoperative data were included. Preoperative coronal varus and valgus stress radiographs (15 N load) were taken using a telos stress device with the knee in 5°–10° of flexion. Varus stress angles were positive if the joint opened on the lateral side, and valgus stress angles were positive if the joint opened on the medial side. The sum of varus and valgus stress angles indicated total joint laxity. During surgery, cases that required tibial recuts to balance the joint were recorded. Patients completed three PROMs and rated their satisfaction. Correlations between laxity and PROMs were evaluated using Pearson's correlation.ResultsStress radiographs revealed varus stress angles of 6.3° ± 3.5° (range, −4.5° to 14.1°), valgus stress angles of 0.1° ± 3.7° (range, −8.0° to 10.9°), and the sum of the varus and valgus stress angle of 6.4° ± 3.3° (range, 0.1° to 17.1°). There were no correlations between laxity and PROMs: r < 0.160 for varus stress angle, r < 0.180 for valgus stress angle and r < 0.160 for the sum of stress angles. There were no statistically significant or clinically relevant differences in PROMs between knees without and those with tibial recuts.ConclusionPreoperative coronal varus or valgus laxity was not correlated with PROMs following individualised TKA at a minimum 2‐year follow‐up. Individualised TKA with personalised alignment enables adequate accommodation of a broad spectrum of preoperative coronal varus–valgus laxities.Level of EvidenceIV

Lower Blood Loss with Bicruciate-Retaining Total Knee Arthroplasty Compared with Bicruciate-Stabilized Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is a common surgical procedure to treat end-stage knee osteoarthritis. This study compared blood loss volume and other clinical outcomes between bicruciate-retaining (BCR) and bicruciate-stabilized (BCS) TKA. Ninety-seven participants who underwent unilateral TKA were enrolled. The BCS-TKA and BCR-TKA groups comprised 78 and 19 participants, respectively. Blood loss was calculated using preoperative and postoperative hematocrit values, height, weight, and sex. Measurements were taken immediately after surgery, on days 1 and 7, and total blood loss was calculated up to day 7. Operation time, range of motion at 7 and 14 days postoperatively, blood transfusion requirement, and postoperative complications such as infection, hematoma, and deep vein thrombosis were compared between the groups. Blood loss was comparable between groups at all time points (125.7 vs. 105.4 mL, 57.9 vs. 43.5 mL, and 68.2 vs. 41.7 mL for immediate, day 1, and day 7 postoperatively, respectively; all p > 0.05) except for total blood loss, which was significantly lower in the BCR group compared with the BCS group (190.7 vs. 251.1 mL; p < 0.05). The BCR group also had a longer operation time than the BCS group (131.2 vs. 112.4 minutes; p < 0.05). No other significant differences were observed in other outcomes. Total blood loss up to 7 days postoperatively was significantly lower in the BCR group than in the BCS group despite a longer operation time. This may be attributed to the reduced bone resection and greater soft tissue preservation, including the anterior cruciate and posterior cruciate ligaments, in the BCR technique.

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.

Feasibility of automated surveillance of implantable devices in orthopaedics via clinical data warehouse: the Studio study

BackgroundTotal hip, knee and shoulder arthroplasties (THKSA) are increasing due to expanding demands in ageing population. Material surveillance is important to prevent severe complications involving implantable medical devices (IMD) by taking appropriate preventive measures. Automating the analysis of patient and IMD features could benefit physicians and public health policies, allowing early issue detection and decision support. The study aimed to demonstrate the feasibility of automated cohorting of patients with a first arthroplasty in two hospital data warehouses (HDW) in France.MethodsThe study included adult patients with an arthroplasty between 2010 and 2019 identified by 2 data sources: hospital discharge and pharmacy. Selection was based on the health insurance thesaurus of IMDs in the pharmacy database: 1,523 distinct IMD references for primary THSKA. In the hospital discharge database, 22 distinct procedures for native joint replacement allowing a matching between IMD and surgical procedure of each patient selected. A program to automate information extraction was implemented in the 1st hospital data warehouse using natural language processing (NLP) on pharmacy labels, then it was then applied to the 2nd hospital.ResultsThe e-cohort was built with a first arthroplasty for THKSA performed in 7,587 patients with a mean age of 67.4 years, and a sex ratio of 0.75. The cohort involved 4,113 hip, 2,630 knee and 844 shoulder surgical patients. Obesity, cardio-vascular diseases and hypertension were the most frequent medical conditions.DiscussionThe implementation of an e-cohort for material surveillance will be easily workable over HDWs France wild. Using NLP as no international IMD mapping exists to study IMD, our approach aims to close the gap between conventional epidemiological cohorting tools and bigdata approach.ConclusionThis pilot study demonstrated the feasibility of an e-cohort of orthopaedic devices using clinical data warehouses. The IMD and patient features could be studied with intra-hospital follow-up and will help analysing the infectious and unsealing complications.

Artificial intelligence-based analysis of lower limb muscle mass and fatty degeneration in patients with knee osteoarthritis and its correlation with Knee Society Score.

Lower-limb muscle mass reduction and fatty degeneration develop in patients with knee osteoarthritis (KOA) and could affect their symptoms, satisfaction, expectation and functional activities. The Knee Society Scoring System (KSS) includes patient reported outcome measures, which is widely used to evaluate the status of knee function of KOA. This study aimed to clarify how muscle mass and fatty degeneration of the lower limb correlate with the KSS in patients with KOA. This study included 43 patients with end-stage KOA, including nine males and 34 females. Computed tomography (CT) images of the lower limb obtained for the planning of total knee arthroplasty were utilized. Ten muscle groups were segmented using our artificial-intelligence-based methods. Muscle volume was standardized by dividing by their height squared. The mean CT value for each muscle group was calculated as an index of fatty degeneration. Bivariate analysis between muscle volume or CT values and KSS was performed using Spearman's rank correlation test. Multiple regression analysis was performed, and statistical significance was set at p < 0.05. Bivariate analysis showed that the functional activity score was significantly correlated with the mean CT value of all muscle groups except the adductors and iliopsoas. Multiple regression analysis revealed that the functional activities score was significantly associated with the mean CT values of the gluteus medius and minimus muscles and the anterior and lateral compartments of the lower leg (β = 0.42, p = 0.01; β = 0.33, p = 0.038; and β = 0.37, p = 0.014, respectively). Fatty degeneration, rather than muscle mass, in the lower-limb muscles was significantly associated with functional activities score of the KSS in patients with end-stage KOA. Notably, the gluteus medius and minimus and the anterior and lateral compartments of the lower leg are important muscles associated with functional activities.

Utilisation of the Hip Disability and Knee Injury Osteoarthritis Outcome Score in physiotherapy following total hip and knee arthroplasty: a cross-sectional survey

Objective To explore the frequency of administration and the usage of the Hip Disability and Knee injury Osteoarthritis Outcome Scores (HOOS/KOOS) and their Physical function Short forms (HOOS-PS/KOOS-PS) by physiotherapists after total hip and knee arthroplasties (THA/TKA). Design A cross-sectional study using an open online survey. Setting Primary care physiotherapy practices affiliated with the Dutch Association for Quality in Physiotherapy. Participants Physiotherapists with experience treating over five patients with a THA or TKA within the past 5 years. Results One hundred and sixty-six physiotherapists completed the survey (median age: 40.0 years, female: 34%, median experience: 15.0 years). Of those, 32 did not administer the HOOS(-PS) or KOOS(-PS) (‘non-users’), 41 administered only due to organisational requirements or guideline recommendations (‘passive users’) and 93 actively used them for individual patient treatment purposes (‘active users’). ‘Treatment evaluation’, ‘diagnosis’, and ‘prognosis’ were most often reported as potential reasons to actively use the HOOS(-PS) or KOOS(-PS) for individual treatment purposes. Determinants associated with active use of the HOOS(-PS) or KOOS(-PS) appeared to be fewer years of experience as a physiotherapist, a larger treatment volume of THA/TKA, a younger age, and higher attitude scores regarding PROM use. Conclusions Most responding physiotherapists administer the HOOS(-PS) or KOOS(-PS), but their use for individual treatment is limited. Active users appear to be less experienced, younger, treat larger volumes of THA/TKA, and possess a more positive attitude towards using patient-reported outcome measures.

Exploring the role of the built environment and psychosocial mediators on knee function in knee osteoarthritis patients in Singapore: a cross-sectional study.

(1) To examine if a more accessible built environment (BE) is significantly associated with better knee function outcomes in knee osteoarthritis (OA) patients. (2) To assess if the relationship between BE and knee function is mediated by fear of movement and self-efficacy. Cross-sectional study. Two tertiary hospitals in Singapore. 212 knee OA patients (mean: 63.81±8.27 years old), majority female (69.8%). (i) meets National Institute for Health and Care Excellence criteria for knee OA, (ii) independent community ambulant. (i) alternative diagnosis to knee OA, (ii) secondary osteoarthritis, (iii) severe medical and/or cognitive comorbidity impairing activities of daily living, (iv) previous knee arthroplasty, (v) wheelchair bound, or (vi) pregnant. PRIMARY AND SECONDARY OUTCOME MEASURES; STATISTICS: How self-efficacy (Arthritis Self-Efficacy Scale-8 (ASES-8)) and fear of movement (Brief Fear of Movement (BFOM)) mediates impact of overall BE (IPAQ-Environment module: Access to Destinations) and five item-specific domains of BE accessibility on knee function (Knee Injury and Osteoarthritis Outcome Score-12 (KOOS-12)). For variables significantly correlated with BE and KOOS-12 in bivariate Pearson correlation tests, mediation analysis was performed with confounders adjusted. Total BE (r=0.142, p=0.038) and accessibility to transit station (r=0.161, p=0.019) were positively correlated with KOOS-12. Structural barriers (r=-0.138, p=0.045) were negatively correlated with KOOS-12. ASES-8 was a significant mediator in the relationship between accessibility to transit station and KOOS-12 (coeff=0.87, 95% CI=(0.24, 1.69), p=0.005) and between total BE and KOOS-12 (coeff=0.25, 95% CI=(0.10, 0.45), p=0.004). BFOM was a marginally significant mediator between structural barriers and KOOS-12 (coeff=-0.36, 95% CI=(-0.86, -0.02); p=0.054). More accessible BE and lesser structural barriers in the BE are associated with better knee function. Self-efficacy mediates the relationship between overall BE accessibility and knee function. Fear of movement mediates the negative association between barriers in the BE and knee function.Applications include assessing BE barriers and psychosocial mediators in clinician consultations, developing multidisciplinary integrated care models and urban designers planning mobility friendly BEs. The study has been registered under clinicaltrials.gov registry (Identifier: NCT04942236).

In Vitro Verification of Simulated Daily Activities Using Implant-Specific Kinematics from In Vivo Measurements

The mechanism and boundary conditions used to drive experimental joint simulators have historically adopted standardized profiles developed from healthy, non-total knee arthroplasty (TKA) patients. The purpose of this study was to use implant-specific in vivo knee kinematics to generate physiologically relevant boundary conditions used in the evaluation of cadaveric knees post-TKA. Implant-specific boundary conditions were generated by combining in vivo fluoroscopic kinematics, musculoskeletal modeling-generated quadriceps loading, and telemetric knee compressive loading during activities of daily living (ADL) to dynamically drive a servo-hydraulic knee joint simulator. Ten cadaveric knees were implanted with the same TKA components and mounted in the knee simulator to verify the resulting load profiles against reported fluoroscopic kinematics and loading captured by an ultra-congruent telemetric knee implant. The cadaveric simulations resulted in implant-specific boundary conditions, which accurately recreate the in vivo performance of the like-implanted knee, with Root Mean Square Error (RMSE) in femoral low point kinematics below 2.0 mm across multiple activities of daily living. This study demonstrates the viability of in vivo fluoroscopy as the source of relevant boundary conditions for a novel knee loading apparatus, enabling dynamic cadaveric knee loading that aligns with clinical observations to improve the preclinical development of TKA component design.

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.

Hidden costs of first choice alternatives: A financial model of thromboprophylaxis and prosthetic joint infection prophylaxis in total knee arthroplasty

BackgroundAspirin has been shown to be equally or more effective than factor Xa inhibitors for thromboprophylaxis following total knee arthroplasty (TKA). Cefazolin has been proven more effective than vancomycin in preventing prosthetic joint infection (PJI) after TKA. This study aimed to compare costs between different drug combinations for prevention of venous thromboembolism (VTE) and PJI following TKA, focusing on costs associated with PJI management. MethodsWe used published PJI rates for TKA patients treated with aspirin or factor Xa inhibitors for thromboprophylaxis, as well as for those who received prophylactic cefazolin or vancomycin. Unit prices for each drug and labor costs associated with vancomycin administration were obtained from our hospital's pharmacy service. The PJI cost model included the price of 2-stage septic TKA revision and national projections of future TKA volume. ResultsThe least expensive average per-patient cost resulted from the combination of aspirin and cefazolin, equating to $521.19 given a 0.8 % PJI rate. The most expensive average per-patient cost was the combination of a factor Xa inhibitor and vancomycin, equaling $5,714.96 given a 1.8 % PJI rate. This extrapolates to an annual cost burden of $19.5 billion by 2040. ConclusionThe average per-patient cost of using a combination of a factor Xa inhibitor and vancomycin is 711 % greater than the combination of aspirin and cefazolin. In this era of value-based care, aspirin and cefazolin should be considered gold standards for TKA thromboprophylaxis and PJI prophylaxis, as they reduce costs and improve patient outcomes.

Patient-Level Factors, Outcomes, and Costs Associated with Facility Transfer following Total Knee Arthroplasty: A Retrospective Database Study

Patient disposition following total knee arthroplasty (TKA) has major implications for patient outcomes and costs. Current studies are limited in sample size and dates of data collection. We evaluated patient factors, outcomes, and costs associated with disposition to a facility following TKA. This was a retrospective cohort study including 1,906,670 patients undergoing TKA from a national wide database, from the years 2016 to 2020. Of these, 25,485 (1.34%) patients were transferred to a facility for rehabilitation. Demographic data, hospital-related outcomes, and postoperative complications were collected. Multivariate regression was performed to assess outcomes associated with facility transfer for rehabilitation. Patients were more likely to be transferred if they were women (Odds Ratio (OR) = 1.10; P < 0.001), greater than 80 years old (OR = 2.25; P < 0.001), had an increased Elixhauser comorbidity index (OR = 1.38; P < 0.001), or were in the lowest income quartile (OR = 1.38; P < 0.001). Transferred patients were more likely to experience medical (OR = 1.92; P < 0.001) and surgical complications (OR = 2.74; P < 0.001), including vascular complications (OR = 2.07; P < 0.001), neurologic complications (OR = 5.72; P < 0.001), and dislocation (OR = 2.01; P < 0.001). They also had greater hospital lengths of stay (OR = 5.27; P < 0.001) and hospital charges (OR = 1.88; P < 0.001); however, they were less likely to undergo reoperation within 30 days (OR = 0.61; P = 0.002). Elderly, lower-income patients who had more comorbidities are more likely to be transferred to a facility following TKA. While there are associated increased costs, complications, and hospital lengths of stay, there are lower rates of reoperation for those who transferred to a facility after TKA.

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.

Influencing factors of kinesiophobia in knee arthroplasty patients under the social cognitive theory: A structural equation model

ObjectiveTo analyze the path relationships among influencing factors for kinesiophobia in knee arthroplasty patients through a structural equation model. BackgroundThe occurrence of kinesiophobia significantly impacts the rehabilitation process of knee arthroplasty patients. However, there is still a need to determine factors that contribute to reducing kinesiophobia. DesignA cross-sectional study was conducted and reported following the STROBE guideline. MethodsBetween February 2022 to October 2022, 162 total knee arthroplasty (TKA) patients and 81 unicompartmental knee arthroplasty (UKA) patients completed a survey. A structural equation modeling (SEM) approach was utilized to analyze the relationships between kinesiophobia and influencing factors (social support, pain resilience, and rehabilitation self-efficacy). Furthermore, multi-group SEM analysis was conducted to examine whether the model equally fitted patients in different types of knee arthroplasty. ResultsThe direct negative effects of rehabilitation self-efficacy (β = −0.535) and pain resilience (β = −0.293) on kinesiophobia were observed. The mediating effect (β = −0.183) of pain resilience and rehabilitation self-efficacy between social support and kinesiophobia was also significant. The SEM model achieved an acceptable model fit (χ2 = 35.656, RMSEA = 0.031, χ2/df = 1.230, GFI = 0.972, NFI = 0.982, IFI = 0.997, CFI = 0.996). In multicohort analysis, no significant differences were observed among knee arthroplasties (TKA, UKA) (Δχ2 = 4.213, p = 0.648). ConclusionsSatisfactory social support enhances pain resilience and rehabilitation self-efficacy, so as to reduce kinesiophobia. Future interventions that directly target the assessment and management of kinesiophobia, available social support may help reduce kinesiophobia, and pain resilience and rehabilitation self-efficacy may be critical factors in managing kinesiophobia. Relevance to Clinical PracticeReducing kinesiophobia in knee arthroplasty patients requires satisfactory social support, pain resilience, and rehabilitation self-efficacy. Therefore, healthcare organizations may implement initiatives to reduce kinesiophobia by taking these factors into account.

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.