Perioperative Differences Between Outpatient and Inpatient Pathways Following Hip and Knee Arthroplasty.

Background: Optimization of clinical pathways and logistics led to the introduction of outpatient joint arthroplasty of the hip and knee. Nevertheless, little is known about what these current protocols look like and how they differ from "standard" inpatient protocols. This study aimed to find preoperative, intraoperative, and postoperative differences between outpatient and inpatient pathways. Methods: A questionnaire (ranging between 23 and 37 items) was developed and administered by email to orthopedic surgeons who were a member of the Dutch Hip Society and Dutch Knee Society. Survey response rate was 38% (N = 117). Results: No significant differences were found in preoperative pathway characteristics. The administration regime for tranexamic acid significantly differed between outpatient and inpatient pathways (P < .001 and P = .002 for hip and knee arthroplasty, respectively), with outpatient pathways using a combined (eg, oral and intravenous) administration regime more frequently. The perioperative antibiotic prophylaxis regime also significantly differed between outpatient and inpatient pathways (P < .001 and P = .014, respectively), with outpatient pathways more frequently incorporating fewer antibiotic doses. Same-day postoperative mobilization significantly less often occurred if surgery took place later that day in inpatient hip arthroplasty pathways (24%; P = .034). Postoperative hemoglobin-check occurred significantly more often on indication in outpatient than in inpatient hip and knee arthroplasty pathways (∼75% vs ∼25%; P = .001). Conclusions: Few intraoperative and postoperative differences in outpatient and inpatient pathways were found and probably mainly relied on logistical grounds. Nonetheless, findings suggested that outpatient pathways tended to be more up-to-date and innovative than inpatient pathways.

High intra- and inter-observer reliability of planning implant size in MRI-based patient-specific instrumentation for total knee arthroplasty.

PURPOSE: Patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) uses individually designed disposable guides to determine intraoperative bone cuts. The manufacturer provides the surgeon with proposed planning which can be modified and should be approved by the surgeon before the guides are produced. This study aims to assess the intra- and inter-observer reliability among preoperative planning by orthopaedic surgeons using PSI. The authors hypothesize a high intra- and inter-observer reliability in planning TKA using PSI. METHODS: Four orthopaedic surgeons modified and approved 40 preoperative MRI-based PSI plannings three times. The surgeons were blinded to their own and each other's results. Intra- and inter-observer reliability was obtained for planned implant size, resection, and position of the implant. RESULTS: Intra-observer reliability Intraclass Correlation Coefficients (ICC) were excellent for femoral and tibial implant size with a range of 0.948-0.995 and 0.919-0.988, respectively. Inter-observer reliability for femoral and tibial implant size showed an ICC range of 0.953-0.982 and 0.839-0.951, respectively. Next to implant size, intra- and inter-observer reliability demonstrated good to an excellent agreement (ICC > 0.75) for 7 out of 12 remaining parameters and 6 out of 12 remaining parameters, respectively. CONCLUSION: Preoperative planning of TKA implant size using MRI-based PSI showed excellent intra- and inter-observer reliability. Further research on the comparison of predicted implant size preoperatively to intraoperative results is needed.

[A man with blisters after a knee replacement]. / Een man met blaren na een knieprothese.

A 62-year old male patient was seen four days after total knee arthroplasty with pain, itchy erythema and blistering surrounding the wound. European Standard Series and wound dressing patch testing was performed. This confirmed the diagnosis allergic contact dermatitis, with the wound dressing as the offending allergen.

Long-term Effects of Cheilectomy, Keller's Arthroplasty, and Arthrodesis for Symptomatic Hallux Rigidus on Patient-Reported and Radiologic Outcome.

BACKGROUND: Several operative interventions are available to alleviate pain in hallux rigidus, and the optimal operative technique is still a topic of debate among surgeons. Three of these are arthrodesis, cheilectomy, and Keller's arthroplasty. Currently, it is unclear which intervention yields the best long-term result. The aim of this study was to assess which of these interventions performed best in terms of patient-reported outcome, pain scores, and disease recurrence at long-term follow-up. METHODS: These data are the follow-up to the initial study published in 2006. In the original study, 73 patients (n = 89 toes) with symptomatic hallux rigidus were recruited and underwent first metatarsophalangeal joint arthrodesis (n = 33 toes), cheilectomy (n = 28 toes), or Keller's arthroplasty (n = 28 toes). Outcome measures were AOFAS hallux metatarsophalangeal-interphalangeal (HMI) score, and pain was assessed with a visual analog scale (VAS) at a mean follow-up period of 7 years. Patients of the original study were identified and invited to participate in the current study. Data were collected in the form of AOFAS-HMI score, VAS pain score, Manchester-Oxford Foot Questionnaire (MOXFQ), and Forgotten Joint Score (FJS-12). In addition, a clinical examination was performed and radiographs were obtained. Data were available for 37 patients (45 toes), with a mean follow-up period over 22 years. RESULTS: AOFAS-HMI and VAS pain score improved during follow-up only in arthrodesis patients. Furthermore, no statistically significant differences in clinical and patient-reported outcome were detected between groups based on AOFAS-HMI, VAS pain, MOXFQ, or FJS-12. However, clinically important differences in patient-reported outcomes and pain scores were detected, favoring arthrodesis. Radiographic disease progression was more evident after cheilectomy compared with Keller's arthroplasty. CONCLUSION: Arthrodesis, cheilectomy, and Keller's arthroplasty are 3 sucessful operative interventions to treat symptomatic hallux rigidus. Because clinically important differences were detected and symptoms still diminish many years after surgery, a slight preference was evident for arthrodesis. LEVEL OF EVIDENCE: Level III, comparative study.

Reasons for Unsuccessful Same-Day Discharge Following Outpatient Hip and Knee Arthroplasty: 5½ Years' Experience From a Single Institution.

BACKGROUND: Outpatient joint arthroplasty (OJA) is considered safe and feasible in selected patients but should be further optimized to improve success rates. The purposes of this study are to (1) identify the main reasons of unsuccessful same-day discharge (SDD) following hip and knee arthroplasty; (2) determine the hospital length of stay (LOS) following unsuccessful SDD; and (3) assess which independent variables are related to specific reasons for unsuccessful SDD. METHODS: Five hundred twenty-five patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty between 2013 and 2019 were retrospectively identified. SDD to home was planned in all patients. Specific reasons for unsuccessful SDD and LOS were assessed. Bivariate analysis was performed to find differences in independent variables between patients experiencing a specific reason for unsuccessful SDD and control patients. RESULTS: One hundred ten patients (21%) underwent unsuccessful SDD. The main reason was postoperative reduced motor function and sensory disturbances (33%). The mean LOS in the unsuccessful SDD group was 1.7 days (standard deviation ± 1.0 days). Postoperative transient reduced motor function and sensory disturbances occurred more often in patients undergoing TKA (P < .001). CONCLUSION: An option for overnight stay should be available when performing outpatient hip and knee arthroplasty. The main reason for unsuccessful SDD in this study was transient postoperative reduced motor function and sensory disturbance, most likely due to intraoperative local infiltration analgesia in TKA. No other studies have found local infiltration analgesia to be an issue preventing SDD.

Predictors of (Un)successful Same-Day Discharge in Selected Patients Following Outpatient Hip and Knee Arthroplasty.

BACKGROUND: It is generally accepted that only selected patients are suitable for outpatient joint arthroplasty (OJA); however, no consensus exists on the optimal selection criteria. We believe patients undergoing OJA should undergo risk stratification and mitigation in an attempt to optimize quality and minimize costs. METHODS: Patient factors of 525 patients who were selected to have primary elective unicompartmental knee arthroplasty (N = 158), total knee arthroplasty (N = 277), or total hip arthroplasty (N = 90) in an outpatient setting were retrospectively reviewed. A complete case multivariable logistic regression analysis of 440 patients was conducted to identify factors that were independently associated with (un)successful same-day discharge (SDD). RESULTS: One hundred ten patients (21%) were not able to be discharged on the day of surgery. Charnley class B2 was associated with a higher chance of successful SDD (odds ratio [OR], 0.29; 95% confidence interval [CI], 0.12-0.72), whereas female gender (OR, 1.7; 95% CI, 1.0-2.8), total knee arthroplasty (OR, 1.9; 95% CI, 1.1-3.4), and a higher American Society of Anesthesiologists (ASA) physical function score (ASA II: OR, 1.9; 95% CI, 1.1-3.3; ASA III: OR, 3.9; 95% CI, 1.1-13) were associated with a higher risk of unsuccessful SDD. CONCLUSION: These results in a preselected population suggest the need for further specifying and improving selection criteria for patients undergoing OJA and emphasize the importance of an in-hospital backup plan for patients at risk of unsuccessful SDD. Previous contralateral joint arthroplasty is a protective factor for successful SDD.

Dutch Translation of the Manchester-Oxford Foot Questionnaire: Reassessment of Reliability and Validity.

The Manchester-Oxford Foot questionnaire (MOxFQ) is a 16-item patient reported outcome measure developed and validated for use in clinical trials involving foot surgery. The purpose of the present study was to evaluate the psychometric properties of the Dutch translation of the MOxFQ in patients who had undergone a hallux valgus correction. A total of 79 patients who had undergone hallux valgus correction completed the Medical Outcomes Study short-form 36-item questionnaire (SF-36) and MOxFQ before and after surgery. We evaluated the construct validity of the SF-36 versus the MOxFQ and the test-retest reliability. The test-retest reliability was excellent. The internal consistency of the Dutch MOxFQ was high (Cronbach's α of 0.74 to 0.86). The construct validity can be regarded as good, with moderate to high correlations between the Dutch MOxFQ and Dutch SF-36 subscales. In conclusion, the Dutch version of the MOxFQ demonstrated good reliability and validity compared with the SF-36 for use in patient groups that have undergone hallux valgus correction.

Long-term Follow-up of a Randomized Controlled Trial Comparing Scarf to Chevron Osteotomy in Hallux Valgus Correction.

BACKGROUND: Hallux valgus is one of the most common foot deformities. This long-term follow-up study compared the results of 2 widely used operative treatments for hallux valgus: the scarf and chevron osteotomy. METHODS: Conventional weight bearing anteroposterior (AP) radiographs of the foot were made for evaluating the intermetatarsal angle and hallux valgus angle. For clinical evaluation, the American Orthopaedic Foot & Ankle Society (AOFAS) rating system for the hallux metatarsophalangeal-interphalangeal scale was used together with physical examination of the foot. These data were compared with the results from the original study. The Short Form 36 questionnaire, the Manchester-Oxford Foot Questionnaire (MOXFQ), and a general questionnaire including a visual analog scale (VAS) pain score were used for subjective evaluation. The primary outcome measures were the radiologic recurrence of hallux valgus and reoperation rate of the same toe. Secondary outcome measures were the results from the radiographs and subjective and clinical evaluation. The response rate was 76% at the follow-up of 14 years; in the chevron group, 37 feet were included compared with 36 feet in the scarf group. RESULTS: Twenty-eight feet in the chevron group and 27 in the scarf group developed recurrence of hallux valgus (P = .483). One patient in the scarf group had a reoperation of the same toe compared with none in the chevron group (P = .314). Current VAS pain scores and results from the SF-36, MOXFQ, and AOFAS did not significantly differ between groups. CONCLUSION: Both techniques showed similar results after 2 years of follow-up. At 14 years of follow-up, neither technique was superior in preventing recurrence. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

Midterm results of posterior arthroscopic ankle fusion.

PURPOSE: The presented study was performed to evaluate the midterm clinical and radiological results and complication rates of the first 40 patients with an ankle fusion through a posterior arthroscopic approach. METHODS: Forty consecutive patients with end-stage post-traumatic ankle osteoarthritis were treated with posterior arthroscopic ankle fusion. All patients were assessed clinically as well as radiologically with a minimum follow-up of 2 years. The Foot and Ankle Ability Measure (FAAM) and Foot Function Index (FFI) were used to assess clinical improvement. RESULTS: Clinical fusion was achieved in 40 patients within 3 months (100%), and radiological fusion was achieved in 40 patients at 12 months. Two screw mal-placements occurred. Both complications were solved following revision surgery. A significant improvement was noted for both the FAAM [median 38 (range 17-56) to 63 (range 9-84)] and FFI scores [median 66 (range 31-89) to 32 (range 11-98)] for all 40 patients. CONCLUSION: The posterior arthroscopic ankle fusion is an effective and safe treatment option for end-stage post-traumatic ankle osteoarthritis at midterm follow-up. LEVEL OF EVIDENCE: Prospective cohort study, Level IV.

Hind- and Midfoot Motion After Ankle Arthrodesis.

BACKGROUND: After ankle arthrodesis (AA), compensatory increased range of motion in adjacent joints might lead to increased osteoarthritis. Evaluation of patient-reported outcomes after AA with validated questionnaires is rare. Likewise, reliable radiographic analysis of the position of the AA, expected to influence the range of motion of the hind- and midfoot, is lacking. Therefore, the current study was performed. METHODS: Seventeen patients with unilateral AA were included. Sagittal hind- and midfoot range of motion was measured radiographically. The position of the AA in the sagittal and coronal planes and osteoarthritis of adjacent joints were also evaluated radiographically. Measurements were compared to the contralateral side. Patient-reported outcomes via validated questionnaires were compared to a control group (n = 18). RESULTS: Average follow-up was 3.5 years. Mean combined hind- and midfoot sagittal range of motion after AA equaled that of the contralateral side (20.8 vs. 21.0 degrees; P = .93). The tibiotalar angle after AA equaled that of the contralateral side (107 vs. 107 degrees; P = .86). The talus was translated posteriorly after AA (T-T ratio 0.45 vs. 0.34; P < .001). Low intraclass correlation coefficients (ICC) precluded reliable evaluation of the coronal position of the hindfoot (ICC, 0.07 and -0.34) and osteoarthritis in adjacent joints (ICC range, 0-0.54). SF-36 physical health scores after AA are lower as compared with those of controls (50 vs. 56; P = .01). Scores on the Foot and Ankle Outcome Score and Ankle Osteoarthritis Scale were also significantly lower. Patient satisfaction with AA was high (average visual analog scale score, 83). CONCLUSION: No increased sagittal range of motion in the hind- and midfoot after AA was found at 3.5 years of follow-up as compared with the contralateral side. Tibiotalar angles were equal. The talus was translated posteriorly. The hindfoot alignment view was not suitable to analyze the position of the hindfoot. Low ICC of the Kellgren and Lawrence scale precluded evaluation of osteoarthritis of adjacent joints. Patients scored lower than controls on self-reported outcome questionnaires but were satisfied with the result of AA.

Safety and efficiency of posterior arthroscopic ankle arthrodesis.

PURPOSE: To study the safety and efficiency of posterior arthroscopic ankle arthrodesis. METHODS: Ten fresh-frozen human lower leg specimens without evidence of previous surgery to the foot and ankle were selected. Arthroscopic debridement of the tibiotalar joint was performed in all specimens using a standardized protocol. Anatomical dissections were regarded the gold standard for safety analysis. To evaluate the efficacy of the posterior ankle arthroscopic arthrodesis, the debrided articular tibiotalar parts were resected and subsequently analysed using Image-analysis software, Image J (Wayne Rasband, National Institutes of Health, Bethesda, MD). RESULTS: In none of the specimens, iatrogenic damage was detected during the anatomical dissection following the posterior ankle arthroscopic procedure. A total talar joint surface area of 95 % and total tibial joint surface area of 96 % was addressed during the arthroscopic debridement. CONCLUSIONS: The posterior ankle arthroscopic arthrodesis can be regarded safe and is also highly effective in the debridement of cartilage, resulting in optimal biology for fusion to occur. Therefore, this new arthroscopic technique potentially will diminish existing non-union rates for the fusion of the ankle joint.

Randomised trial comparing bone remodelling around two uncemented stems using modified Gruen zones.

For assessment of bone remodelling around total hip arthroplasty using dual-emission X-ray absorptiometry (DEXA), a variety of different systems to identify regions of interest (ROI) have been used, making comparisons between stem designs difficult. The Gruen zones are now widely used for this purpose. We present the results of a randomised clinical trial comparing 2 uncemented stem designs with proximal coating, using a modification of the Gruen zones to allow improved representation of the effect of the implant on bone mineral density (BMD) over time. DEXA-data were used in a randomised trial with 2 years follow up, comparing the uncemented Symax(TM) (n=25) and Omnifit(®) (n=24) stems. The effect on BMD was determined using the 'standard' adapted Gruen zones, and a modification which studied an equal length and position for zones 1 and 7 around both stems, assuring that the same regions in terms of cancellous and cortical bone were compared. The 'modified' regions of interest give lower BMD values around the Omnifit(®) than using the 'standard' Gruen zones (3.6 % in zone 7, p<0.05). The difference with the Symax(TM) BMD values, which had been concealed using the standard Gruen zones, became statistically significant in favour of the Symax(TM) implant. This adaptation can detect a statistically significant difference in bone preservation in zone 7 between stems that would otherwise not have been revealed. We recommend the use of 'modified' Gruen zones for more valid comparison of remodelling caused by different implant designs.

Above- or below-elbow casts for distal third forearm fractures in children? A meta-analysis of the literature.

INTRODUCTION: Fractures of the distal third forearm are common fractures in childhood. Most of these fractures can be treated non-operatively by means of closed reduction and immobilization. The purpose of this meta-analysis is to investigate whether above- or below-elbow cast should be considered the first-choice for conservative treatment. MATERIALS AND METHODS: A search was performed in multiple databases to identify all the studies comparing above- and below-elbow cast for the treatment of distal third forearm fractures in children. All RCT's or CCT's were assessed for eligibility. Quality was assessed by the Cochrane Musculoskeletal Injuries Group assessment. Data were pooled using RevMan 5.0 RESULTS: Three trials involving a total of 300 participants were included. A total of 142 fractures were treated with a below-elbow cast (BEC) versus 158 with an above-elbow cast (AEC). Loss of reduction was encountered in 17 and 36 cases, respectively [odds ratio 0.44 (0.22-0.87)]. For combined radius and ulna fractures 15 of 97 in the BEC group and 34 out of 122 in the AEC group showed loss of reduction [odds ratio 0.55 (0.26-1.15)]. Children treated with BEC missed less school days [mean difference 1.12 (-1.52 to -0.59)], and encountered less difficulties in daily living [odds ratio 112.41 (6.58-1920.77)]. CONCLUSION: Due to heterogeneity, the trials are not fully compared. Based on the presented meta-analysis, we conclude that BEC is not inferior to AEC so that this is a valid treatment option for distal third forearm fractures.

Medium- to long-term outcome of ankle arthrodesis.

BACKGROUND: Despite improvement in outcome after ankle arthroplasty, fusion of the ankle joint is still considered the gold standard. A matter of concern is deterioration of clinical outcome as a result of loss of motion and advancing degeneration of adjacent joints. We performed a long-term study to address these topics. METHODS: Between 1990 and 2005 a total of 121 ankle arthrodeses were performed at our institute. Thirty-five cases were excluded because of simultaneous subtalar arthrodesis. Ten had died and ten were lost to followup. Six had a bilateral ankle arthrodeses, leaving 60 patients (66 ankles) eligible for followup. There were 40 males and 26 females with a mean age at surgery of 47 years. In 60 ankles, fusion was obtained using a two-incision, three-screw technique. All patients were assessed using validated questionnaires and clinical rating systems: Short Form 36 (SF-36), American Orthopaedic Foot and Ankle Society (AOFAS) Ankle and Hindfoot scale, Foot and Ankle Ability Measure (FAAM) and a subjective satisfaction rating. Radiological progression of osteoarthritis of the adjacent joints was assessed. RESULTS: Fusion was achieved in 91% after primary surgery. In six patients rearthrodesis was needed to obtain fusion. The mean SF-36 score was 63 (SD, 22) for the physical component scale and 81 (SD, 15) for the mental component scale. The mean FAAM score was 69 (SD, 17) and the mean AOFAS Ankle Hindfoot score was 67 (SD, 12). Ninety-one percent were satisfied with their clinical result. Infection occurred once. No other serious adverse events were encountered. In all contiguous joints significant progression of arthritis was appreciated. CONCLUSION: Ankle arthrodesis using a two-incision, three-screw technique was a reliable and safe technique for the treatment of end-stage osteoarthritis of the ankle. It resulted in a good functional outcome at a mean followup of 9 years. Progressive osteoarthritis of the contiguous joints was clearly appreciated but the functional and clinical importance of these findings remains unclear.