Comparison of Early Postoperative Step and Stair Counts With the Direct Anterior Approach Versus the Posterior Approach for Total Hip Arthroplasty.

BACKGROUND: The purpose of this study was to evaluate the impact of direct anterior approach (DAA) or posterior approach (PA) on step and stair counts after total hip arthroplasty using a remotely monitored mobile application with a smartwatch while controlling for baseline characteristics. METHODS: This is a secondary data analysis from a prospective cohort study of patients utilizing a smartphone-based care management platform. The primary outcomes were step and stair counts and changes from baseline through one year. Step and stair counts were available for 1,501 and 847 patients, respectively. Longitudinal regression models were created to control for baseline characteristics. RESULTS: Patients in the DAA group had significantly lower body mass index (P = .049) and comorbidities (P = .028), but there were no significant differences in age (P = .225) or sex (P = .315). The DAA patients had a higher average and improvement from baseline in step count at 2 and 3 weeks postoperatively after controlling for patient characteristics (P = .028 and P = .044, respectively). The average stair counts were higher for DAA patients at one month postoperatively (P = .035), but this difference was not significant after controlling for patient demographics. Average stair ascending speeds and changes from baseline were not different between DAA and PA patients. Descending stair speed was higher at 2 weeks postoperatively for DAA patients, but was no longer higher after controlling for baseline demographics. CONCLUSIONS: After controlling for baseline characteristics, DAA patients demonstrate earlier improvement in step count than PA patients after total hip arthroplasty. However, patient selection and surgeon training may continue to influence outcomes through a surgical approach.

Evaluation of weight loss counsel for Osteoarthritis patients: A cross-sectional analysis of NHANES 2011-2018.

OBJECTIVE: Though health care providers (HCPs) know the importance of weight loss counsel for Osteoarthritis (OA), little is known about how frequently it is practiced and even less of its effectiveness. Thus, we analyzed the prevalence and effectiveness of weight counsel receipt in overweight/obese OA patients. DESIGN: Using 2011-2018 National Health and Nutrition Examination Survey data, we cross-sectionally analyzed overweight/obese patients in the United States to determine the prevalence of receipt of HCP weight counsel in those with OA and among other variables. We used multivariate logistic regression models to calculate odds ratios of being counseled and of achieving ten percent weight loss in groups with and without counsel. Mean weight losses were also compared among groups. RESULTS: 39,156 patients were identified, of whom 1948 met inclusion criteria. Overall, 51.89% of overweight/obese OA patients received weight counseling. The odds of receiving counsel varied with several demographic variables. The odds of achieving 10% weight loss in those counseled was 1.84 times (95% confidence interval: 1.028, 3.299) that of those not counseled (p = 0.04). In contrast, patients counseled lost a mean of 0.49 pounds while those not counseled gained a mean of 0.03 pounds, a difference which was not statistically significant (p = 0.59). CONCLUSION: Prevalence of weight counsel receipt for OA has not changed significantly between 2011 and 2018. Though counsel for weight more frequently leads to adequate weight loss in those with OA, the average weight loss is minimal regardless of counsel. Thus, refinement of this intervention may be needed to bolster weight loss.

Analyzing the Quality and Readability of Online Hyaluronic Acid Knee Injection Resources.

INTRODUCTION: We analyzed the quality of information about Hyaluronic acid (HA) knee injections for osteoarthritis using DISCERN, a tool that grades the quality of websites. We also analyzed readability with Flesch-Kincaid grade reading levels (FKGRL). METHODS: Lists of the top ten included sites from Google searches about HA injections were evaluated using DISCERN to determine their quality. Additional variables collected were site category, Health on Net (HON) certification, search result rank, and FKGRL. DISCERN scores were compared and grouped by these variables. RESULTS: Most sites were measured as fair in quality. Greater DISCERN scores were produced from searches using general terminology, sites with HON labels, and academic journal publications. CONCLUSION: This study indicates information quality for HA injections online is fair. The data also indicates that patients can best educate themselves using HON labels, general search terms, and information from academic journals when possible.

Robotic-Assisted Total Knee Arthroplasty Has Similar Rates of Prosthetic Noise Generation as Conventional Total Knee Arthroplasty.

Background: Noise has been reported to occur with relatively high frequency after conventional total knee arthroplasty (C-TKA), and this may impact the incidence of patient satisfaction and function. The purpose of this study was to compare the rate of patient-reported prosthetic noise generation after robotically-assisted TKA (RA-TKA) and C-TKA. Methods: A retrospective study was conducted of unilateral primary RA-TKAs and C-TKAs performed between 2018 and 2021. Patients completed a survey consisting of 4 Likert scale questions related to prosthetic noise generation and Knee Injury and Osteoarthritis Score Joint Replacement and Forgotten Joint Score were assessed prospectively preoperatively and at a minimum of 1-year of clinical follow-up. Statistical analysis was done utilizing T-tests and chi-square tests, with statistical significance defined as a P-value < .05. Results: One hundred sixty-two RA-TKAs and 320 C-TKAs with similar baseline characteristics and functions were included. There were no significant differences in hearing or feeling grinding, popping, clicking, or clunking (40.7% vs 38.1%; P = .647) between groups. Most RA-TKAs and C-TKAs were not dissatisfied regarding noise generation (70.4% vs 73.1%; P = .596). In both cohorts, patients who reported noise generation had lower average Forgotten Joint Scores (45.5 vs 66.1; P < .001) and lower postoperative Knee Injury and Osteoarthritis Score Joint Replacement scores (72.0 vs 81.4; P < .001) than those who did not experience noise generation. Conclusions: While RA-TKA may facilitate soft tissue balancing, there were no differences in prosthetic noise generation between RA-TKA and C-TKA. However, those who experience implant-generated noise have lower functional outcome scores.

Femoral Condyle Insufficiency Fracture After Total Knee Arthroplasty Using a Stemless Femoral Component With a Midlevel Constraint Articular Surface.

Midlevel constraint prostheses have provided increased varus/valgus and rotational stability for patients with severe deformity or ligamentous instability undergoing total knee arthroplasty (TKA). Here we present a series of 5 patients, 2 in detail, who underwent a primary TKA with a midlevel constraint articular surface and a primary femoral component without stem extension who all suffered isolated medial femoral condyle insufficiency fractures. All 5 TKAs were performed in females with both preoperative valgus deformity and flexion contractures. Patients had an average age of 74.4 years, height 62.4 in, and weight 156.2 lbs. Revision TKA was performed in 4 of 5 cases. As a result of these cases, we now routinely consider implanting a stemmed femoral component in this population with osteoporotic medial femoral condyles.

Improved accuracy and reproducibility of a novel CT-free robotic surgical assistant for medial unicompartmental knee arthroplasty compared to conventional instrumentation: a cadaveric study.

PURPOSE: Alignment errors in medial unicompartmental knee arthroplasty (UKA) predispose to premature implant loosening and polyethylene wear. The purpose of this study was to determine whether a novel CT-free robotic surgical assistant improves the accuracy and reproducibility of bone resections in UKA compared to conventional manual instrumentation. METHODS: Sixty matched cadaveric limbs received medial UKA with either the ROSA® Partial Knee System or conventional instrumentation. Fifteen board-certified orthopaedic surgeons with no prior experience with this robotic application performed the procedures with the same implant system. Bone resection angles in the coronal, sagittal and transverse planes were determined using optical navigation while resection depth was obtained using calliper measurements. Group comparison was performed using Student's t test (mean absolute error), F test (variance) and Fisher's exact test (% within a value), with significance at p < 0.05. RESULTS: Compared to conventional instrumentation, the accuracy of bone resections with CT-free robotic assistance was significantly improved for all bone resection parameters (p < 0.05), other than distal femoral resection depth, which did not differ significantly. Moreover, the variance was significantly lower (i.e. fewer chances of outliers) for five of seven parameters in the robotic group (p < 0.05). All values in the robotic group had a higher percentage of cases within 2° and 3° of the intraoperative plan. No re-cuts of the proximal tibia were required in the robotic group compared with 40% of cases in the conventional group. CONCLUSION: The ROSA® Partial Knee System was significantly more accurate, with fewer outliers, compared to conventional instrumentation. The data reported in our current study are comparable to other semiautonomous robotic devices and support the use of this robotic technology for medial UKA. LEVEL OF EVIDENCE: Cadaveric study, Level V.

Success of Various Marketing Strategies for a New-to-the-Area Orthopedic Practice.

Background Competition for patients among orthopaedic private practices, multi-specialty groups, and hospital systems continues to persist. An effective marketing campaign is essential for a practice to succeed in this competitive environment. The purpose of this study was to investigate the cost-effectiveness and efficacy of each marketing campaign and the influence of patient demographics on efficacy. Methods The first 300 consecutive, new patients were prospectively surveyed on how they initially discovered and then selected the orthopaedic practice. Demographics and marketing costs were tabulated and categorized to analyze the effectiveness of each marketing strategy. Results A substantial portion of the marketing budget was allocated for traditional (67.0%) and online advertising (25.0%). However, only 56/300 (18.7%) patients surveyed were brought to the practice by these methods combined. In contrast, expenditure on a marketing liaison (8.0%) delivered 128 patients (42.7%) through referrals: 80 (26.7%) from physicians, 28 (9.3%) from urgent cares, 17 (5.7%) from physical therapists, and 3 (1.0%) from attorneys. Conclusion Marketing strategies were not proportionally beneficial during the first six months of the orthopaedic practice start-up period. During this early ramping up period, the most cost-effective marketing strategy was utilization of a liaison for direct in-person visits to various healthcare facilities.

Patient Perception of Physician Attire in the Outpatient Setting During the COVID-19 Pandemic.

INTRODUCTION: In response to the SARS-CoV-2 pandemic, physician attire has evolved to incorporate personal protective equipment (PPE). Although PPE is mandated for all healthcare workers, variability exists in choice and availability. The purpose of this study was to determine patient perception of physician attire during the COVID-19 pandemic in an outpatient setting. METHODS: Three hundred sixty-eight patients who presented to our outpatient orthopaedic clinics completed an anonymous survey. In addition to demographic characteristics, patient preferences for attire, PPE, and social distancing were obtained. RESULTS: Scrubs (81%, 298/368) were found to be the most acceptable physician attire. Eye protection (34.2%, 126/368) and gloves (32.6%, 120/368), however, were deemed much less acceptable; 93.5% (344/368) of patients reported that no mask was unacceptable, with 41.0% (151/368) preferring a surgical mask. Predilection for a surgical mask and N95 rose with increasing patient education level. Interestingly, 55.2% (203/368) responded that physicians should stop wearing PPE only when the Center for Disease Control recommends. CONCLUSION: During the COVID-19 pandemic, most of the patients found scrubs to be the most acceptable attire in an office-based outpatient setting. Patients also found physician mask-wearing to be important but are less accepting of providers wearing eye and hand protection.

2021 John N. Insall Award: Aspirin is effective in preventing propagation of infrapopliteal deep venous thrombosis following total knee arthroplasty.

AIMS: The optimal management of an infrapopliteal deep venous thrombosis (IDVT) following total knee arthroplasty (TKA) remains unknown. The risk of DVT propagation and symptom progression must be balanced against potential haemorrhagic complications associated with administration of anticoagulation therapy. The current study reports on a cohort of patients diagnosed with IDVT following TKA who were treated with aspirin, followed closely for development of symptoms, and scanned with ultrasound to determine resolution of IDVT. METHODS: Among a cohort of 5,078 patients undergoing TKA, 532 patients (695 TKAs, 12.6%) developed an IDVT between 1 January 2014 to 31 December 2019 at a single institution, as diagnosed using Doppler ultrasound at the first postoperative visit. Of the entire cohort of 532 patients with IDVT, 91.4% (486/532) were treated with aspirin (325 mg twice daily) and followed closely. Repeat lower limb ultrasound was performed four weeks later to evaluate the status of IDVT. RESULTS: Follow-up Doppler ultrasound was performed on 459/486 (94.4%) patients and demonstrated resolution of IDVT in 445/459 cases (96.9%). Doppler diagnosed propagation of IDVT to the popliteal vein had occurred in 10/459 (2.2%) cases. One patient with an IDVT developed a pulmonary embolus six weeks postoperatively. CONCLUSION: The results of this study demonstrate a low rate of IDVT propagation in patients managed with aspirin. Additionally, no significant bleeding episodes, wound-related complications, or other adverse events were noted from aspirin therapy. Cite this article: Bone Joint J 2021;103-B(6 Supple A):18-22.

Better accuracy and reproducibility of a new robotically-assisted system for total knee arthroplasty compared to conventional instrumentation: a cadaveric study.

PURPOSE: Robotically-assisted total knee arthroplasty (TKA) has been shown to improve alignment and decrease outliers, an important goal in TKA procedures. The purpose of this cadaveric study was to compare the accuracy and reproducibility of a recently introduced TKA robotic system to conventional instrumentation for bone resections. METHODS: This cadaveric study compared 14 robotically-assisted TKA with 20 conventional TKAs. Four board-certified high volume arthroplasty surgeons with no prior experience in robotics (except one) performed the procedures with three different implant systems. Angle and level of bone resections obtained from optical navigation or calliper measurements were compared to the intra-operative plan to determine accuracy. Group comparison was performed using Student t test (mean) and F test (variance), with significance at p < 0.05. RESULTS: The robotic group demonstrated statistically more accurate results (p < 0.05) and fewer outliers (p < 0.05) than conventional instrumentation when aiming for neutral alignment. Final limb alignment (HKA) had an accuracy of 0.8° ± 0.6° vs 2.0° ± 1.6°, with 100% vs 75% of cases within 3° and 93% vs 60% within 2°. For the robotically-assisted knees, the accuracy of bone resection angles was below 0.6° with standard deviations below 0.4°, except for the femur flexion (1.3° ± 1.0°), and below 0.7 mm with standard deviations below 0.7 mm for bone resection levels. CONCLUSION: This in vitro study has demonstrated that this novel TKA robotic system produces more accurate and more reproducible bone resections than conventional instrumentation. It supports the clinical use of this new robotic system. LEVEL OF EVIDENCE: Cadaveric study, Level V.