Is Immediate Postoperative Radiograph Necessary Following Robotic-Assisted Total Knee Arthroplasty?

The necessity of immediate postoperative radiographs following total knee arthroplasty (TKA) has long been debated. With the increasing use of robotic-assisted TKA (RTKA), and thus more precise implant placement, the need for immediate postoperative radiographs to determine implant positioning may be unnecessary. We sought to evaluate implant position on the immediate postoperative radiographs following RTKA to determine their necessity. A retrospective review of 150 RTKAs was performed. The posterior slopes for all TKAs were recorded based on the preoperative three-dimensional template. Additionally, two independent trained researchers (J.G./L.B.) each measured the posterior slope of the postoperative day 0 (POD0) radiograph and postoperative week 2 radiograph. The difference in posterior slope measurement between template and POD0, between template and postoperative week 2, and between POD0 and postoperative week 2 was calculated. Of the 150 TKAs performed, there were no periprosthetic fractures found on the POD0 radiograph. The mean difference between the templated posterior slope and measured posterior slope on POD0 was 0.04 degrees (standard deviation [SD], 1.01; p = 0.615). There was a weak correlation between the two values (rs [95% confidence interval (CI)], 0.38 [0.21, 0.53]). When comparing the template to the postoperative week 2 radiographs, there was a mean difference of 0.02 degrees (SD, 0.48; p = 0.556).  However, a moderate to strong correlation was noted (rs [95% CI], 0.71 [0.61, 0.79]). Comparison of the mean posterior slope from POD0 radiograph to that of postoperative week 2 radiograph showed a mean difference of 0.06 degrees (SD, 1.0; p = 0.427). A weak correlation was found between these two values (rs [95% CI], 0.43 [0.26, 0.56]). Given the accuracy and precision of RTKA, along with the ability to decrease cost and radiation, immediate postoperative radiograph may be unnecessary, when pertaining to the uncomplicated RTKA. However, if there is concern for intraoperative fracture, long stems placed in a revision arthroplasty, or other intraoperative complications, then postoperative radiographs are encouraged.

Outcomes of Name-brand Versus Generic Cephalomedullary Nail Fixation for Intertrochanteric and Subtrochanteric Fractures: A Matched Cohort Study.

This study aims to compare 90-day and 6-month outcomes and implant costs of intertrochanteric and subtrochanteric fracture fixation using cephalomedullary nails (CMNs) from a single name-brand company to fixation using generic CMNs. This was a retrospective matched cohort study. All CMN procedures for a single surgeon in a single US metropolitan institution from 2021 to 2022 were identified using current procedural terminology codes. Nearest neighbor 1:1 matching was conducted between the name-brand and generic cohorts controlling for (1) age, (2) American Society of Anesthesiologists score, and (3) Charlson Comorbidity Index. A total of 50 patients were successfully matched (25 namebrand versus 25 generic). The average implant cost per case for the name-brand group was $3,587 versus $1,615 for the generic group. Cost of disposables averaged $109 for the generic implant sets versus $916 for the name-brand (P < 0.001). Overall, a cost savings of 61% could be generated per case with the use of generic implants and disposables. Fixation of intertrochanteric and subtrochanteric fractures using generic CMNs produces similar outcomes compared with using name-brand CMNs for approximately half the implant cost.

Cost Reduction for Knee-Spanning External Fixation in the Staged Treatment of Tibial Plateau Fractures: A Practical Intervention.

OBJECTIVE: To determine whether an educational intervention affects surgeon implant decision making measured by total implant costs for temporizing a knee-spanning external fixation construct. DESIGN: A total of 24 cases were prospectively collected after an educational intervention and matched to 24 cases before intervention using Schatzker classification and by surgeon. SETTING: A single Level 1 trauma center. PATIENTS/PARTICIPANTS: Forty-eight patients with Schatzker II-VI tibial plateau fractures. INTERVENTION: Education session to create transparency with component pricing and to provide 3 clinical cases of Orthopaedic Trauma Association/AO 41-C3 (Schatzker VI) with accompanying images and fixator construct costs. Total implant costs displayed in the session ranged from $2354 to $11,696. OUTCOME MEASUREMENT: External fixator construct cost. RESULTS: The mean cost of constructs in the postintervention group was $4550.20 [95% confidence interval (CI) $3945.60-$5154.00], which was significantly different compared with the preintervention group cost of $6046.75 (95% CI = $5309.54-$6783.97, P = 0.003). After 1 year, the total implant costs of external fixation constructs were reduced by an average of almost $1500 per patient. CONCLUSION: An educational intervention created a reduction in the average total implant construction costs for temporary knee-spanning external fixation in the treatment of tibial plateau fractures. Surgical implant selection and cost variance remain an ideal area to improve value for patients and hospitals. Empowering surgeons with knowledge regarding implant prices is a critical part of working toward the cost reductions of external fixation constructs.

Opioid Use After Common Sports Medicine Procedures: A Systematic Review.

CONTEXT: The prescription of opioids after elective surgical procedures has been a contributing factor to the current opioid epidemic in North America. OBJECTIVE: To examine the opioid prescribing practices and rates of opioid consumption among patients undergoing common sports medicine procedures. DATA SOURCES: A systematic review of the electronic databases EMBASE, MEDLINE, and PubMed was performed from database inception to December 2018. STUDY SELECTION: Two investigators independently identified all studies reporting on postoperative opioid prescribing practices and consumption after arthroscopic shoulder, knee, or hip surgery. A total of 119 studies were reviewed, with 8 meeting eligibility criteria. STUDY DESIGN: Systematic review. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: The quantity of opioids prescribed and used were converted to milligram morphine equivalents (MMEs) for standardized reporting. The quality of each eligible study was evaluated using the Methodological Index for Non-Randomized Studies. RESULTS: A total of 8 studies including 816 patients with a mean age of 43.8 years were eligible for inclusion. A mean of 610, 197, and 613 MMEs were prescribed to patients after arthroscopic procedures of the shoulder, knee, and hip, respectively. At final follow-up, 31%, 34%, and 64% of the prescribed opioids provided after shoulder, knee, and hip arthroscopy, respectively, still remained. The majority of patients (64%) were unaware of the appropriate disposal methods for surplus medication. Patients undergoing arthroscopic rotator cuff repair had the highest opioid consumption (471 MMEs), with 1 in 4 patients receiving a refill. CONCLUSION: Opioids are being overprescribed for arthroscopic procedures of the shoulder, knee, and hip, with more than one-third of prescribed opioids remaining postoperatively. The majority of patients are unaware of the appropriate disposal techniques for surplus opioids. Appropriate risk stratification tools and evidence-based recommendations regarding pain management strategies after arthroscopic procedures are needed to help curb the growing opioid crisis.

Treatment of a Neglected Patellar Tendon Rupture with a Modified Surgical Technique: Ipsilateral Semitendinosus Autograft Reconstruction with Suture Tape Augmentation.

Patellar tendon ruptures are rare, but debilitating injuries are typically seen in young active males in the third and fourth decades of life. They can occur as a single acute injury or from repetitive microtrauma weakening the tendon. Patients typically present complaining of knee pain, swelling, and an inability to perform a straight leg raise. Most conventionally, these injuries are classified as acute (less than two weeks) or chronic (greater than two weeks) based upon the timing of presentation. In patients with patellar tendon ruptures and inability to perform a straight leg raise, patellar tendon repair is most often recommended. A subset of patients with chronic patellar tendon ruptures, however, presents several months after their initial injuries. These neglected patella tendon ruptures present a particularly challenging clinical scenario in which primary repair is often difficult or not possible. This case report describes a modification to an existing surgical technique for reconstructing the patellar tendon using an ipsilateral semitendinosus tendon autograft with suture tape augmentation.

Correction to: Clinical and immunologic evaluation of three metastatic melanoma patients treated with autologous melanoma-reactive TCR-transduced T cells.

The authors would like to make the following corrections to the published article.

Clinical and immunologic evaluation of three metastatic melanoma patients treated with autologous melanoma-reactive TCR-transduced T cells.

Malignant melanoma incidence has been increasing for over 30 years, and despite promising new therapies, metastatic disease remains difficult to treat. We describe preliminary results from a Phase I clinical trial (NCT01586403) of adoptive cell therapy in which three patients received autologous CD4+ and CD8+ T cells transduced with a lentivirus carrying a tyrosinase-specific TCR and a marker protein, truncated CD34 (CD34t). This unusual MHC Class I-restricted TCR produces functional responses in both CD4+ and CD8+ T cells. Parameters monitored on transduced T cells included activation (CD25, CD69), inhibitory (PD-1, TIM-3, CTLA-4), costimulatory (OX40), and memory (CCR7) markers. For the clinical trial, T cells were activated, transduced, selected for CD34t+ cells, then re-activated, and expanded in IL-2 and IL-15. After lymphodepleting chemotherapy, patients were given transduced T cells and IL-2, and were followed for clinical and biological responses. Transduced T cells were detected in the circulation of three treated patients for the duration of observation (42, 523, and 255 days). Patient 1 tolerated the infusion well but died from progressive disease after 6 weeks. Patient 2 had a partial response by RECIST criteria then progressed. After progressing, Patient 2 was given high-dose IL-2 and subsequently achieved complete remission, coinciding with the development of vitiligo. Patient 3 had a mixed response that did not meet RECIST criteria for a clinical response and developed vitiligo. In two of these three patients, adoptive transfer of tyrosinase-reactive TCR-transduced T cells into metastatic melanoma patients had clinical and/or biological activity without serious adverse events.