Cryoneurolysis Associated with Improved Pain, Function, and Sleep in Patients Following Total Knee Arthroplasty: Use of a New Real-World Registry.

INTRODUCTION: Total knee arthroplasty (TKA) is performed on approximately 790,000 patients annually in the United States and is projected to increase to 1.5 million by 2050. This study aimed at assessing the use of preoperative cryoneurolysis on patients undergoing TKA by analyzing: 1) pain severity; 2) opioid use; 3) functional status; and 4) sleep disturbance over 6 months following discharge. METHODS: Patients enrolled in the Innovations in Genicular Outcomes Registry (iGOR) between September 2021 and February 2024 were followed for 6 months. Our analyses included patients undergoing unilateral primary TKA with no pre-operative opioid prescription who either received, or did not receive, cryoneurolysis. Baseline patient demographics were collected before TKA and tabulated. Pain management was assessed via the Brief Pain Inventory-Short Form (BPI-SF) instrument for pain severity. Sleep disturbance was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaire. Each outcome measure was assessed prior to TKA, weekly, and at monthly follow-up. Data was analyzed by a generalized linear mixed-effect regression model to compare cryoneurolysis versus control patients, with a P < 0.05 as significant. RESULTS: There were 80 patients who were treated with preoperative cryoneurolysis, while 60 control patients did not have treatment. Patients receiving cryoneurolysis experienced significantly lower pain severity and sleep disturbance over the 6-month follow-up than control patients (P = 0.046). Cryoneurolysis was also associated with a trend toward greater functional improvement that did not reach statistical significance (P = 0.061). Further, patients who underwent cryoneurolysis were 72% less likely than controls to take opioids over six months following discharge (P <0.001). CONCLUSIONS: Pre-operative cryoneurolysis therapy in opioid-naïve patients undergoing TKA is associated with improved pain, decreased opioid use, and improved sleep disturbance for 6 months postoperatively. Cryoneurolysis, a non-opioid pain relief modality administered pre-operatively, demonstrated substantial benefits in patients who underwent TKA.

Improved Pain and Function with Triamcinolone Acetonide Extended-Release and Cryoneurolysis for Knee Osteoarthritis: Use of a New Real-World Registry.

INTRODUCTION: Knee osteoarthritis (OA) affects 19% of American adults over 45 years old and costs $27+ billion annually. A wide range of non-operative treatment options are available. This study compared six treatments: cryoneurolysis with deep genicular nerve block (Cryo-Deep/Both), cryoneurolysis with superficial nerve block (Cryo-Superficial), intra-articular hyaluronic acid (IA-HA) injections, non-steroidal anti-inflammatory drug injections (IA-NSAIDs), IA-corticosteroids (IA-CS) injections, or IA-triamcinolone extended release (IA-TA-ER) injections over 4 months for: 1) pain severity and analgesic use; and 2) physical function (from Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR)). METHODS: Patients who had unilateral knee OA and received non-operative intervention were enrolled in the Innovations in Genicular Outcomes (iGOR) registry, a novel, multi-center real-world registry, between September 2021 and February 2024. A total of 480 patients were enrolled. Both pain and functional outcomes were assessed at baseline, weekly, and monthly, which were analyzed by: overall trend, magnitude changes pre- to post-treatment, and distribution-based minimal clinically important difference score (MCID). Multivariate linear regressions with adjustments for seven confounding factors were used to compare follow-up outcomes among six treatment groups. RESULTS: Use of IA-TA-ER injections was associated with the lowest pain, greatest pain reduction, and highest prevalence of patients achieving MCID relative to other treatments (P < 0.001). Deep/Both-Cryo and IA-CS were associated with a higher prevalence of achieving MCID than IA-HA, IA-NSAIDs, and Cryo-Superficial (P ≤ 0.001). Use of IA-TA-ER was also associated with the greatest functional score, improvement from baseline, and highest prevalence of patients achieving MCID than other treatments (P ≤ 0.003). CONCLUSIONS: The IA-TA-ER appears to outperform other treatments in terms of pain relief and functional improvement for up to 4 months following treatment. In addition, outcomes in the novel cryoneurolysis and conventional IA-CS were similar to one another and better than those in IA-HA and IA-NSAIDs.

Extended-Release Versus Immediate-Release Triamcinolone Acetonide in Patients Who Have Knee Osteoarthritis and Type 2 Diabetes Mellitus.

BACKGROUND: Intra-articular (IA) corticosteroid injections may cause hyperglycemia (glucose level > 180 mg/dL). In a phase 2 study of 33 patients who had osteoarthritis of the knee (OAK) and type 2 diabetes mellitus (T2D), triamcinolone acetonide extended-release (TA-ER) was associated with minimal glycemic control disruption compared with triamcinolone acetonide immediate-release (TA-IR). This post hoc analysis characterizes the clinical relevance of these results. METHODS: Patients who had symptomatic OAK for ≥ 6 months, T2D for ≥ 1 year, and hemoglobin A1c ≥ 6.5 and ≤ 9.0% were randomized to receive an IA injection of either TA-ER or TA-IR. Changes in continuous glucose monitor daily glucose level, percentage of time in or above the target glucose range (> 70 to 180 mg/dL), time to glucose level 250 mg/dL and maximum glucose level > 250 mg/dL, and glycemic variability were evaluated. RESULTS: Across postinjection days 1 to 3, the TA-ER group (n = 18) had a lower median change from baseline in maximum glucose level (92.3 versus 169.1 mg/dL), a reduced percentage of time with a glucose level > 250 mg/dL (12 versus 26%), a smaller proportion of patients who had a maximum glucose level > 250 mg/dL (50 versus 93%), and a greater percentage of time in the target glucose range (62 versus 48%) versus the TA-IR group (n = 15). There was less glycemic variability and lower glucose spikes in the TA-ER versus TA-IR group. Median times to glucose level 250 mg/dL (44 versus 6 hours) and maximum glucose level (34 versus 13 hours) were significantly longer in the TA-ER versus TA-IR group. CONCLUSIONS: Use of TA-ER was associated with a clinically meaningful reduction in hyperglycemia versus TA-IR.

Isolated Liner Exchange Versus All-Component Revision for Instability After Total Knee Arthroplasty.

BACKGROUND: Instability is a common cause for revision total knee arthroplasty (TKA). The risks and benefits of polyethylene liner exchange (LE) as compared to full metal component revision continue to be debated. The purpose of this study was to investigate the success rate and complication profiles of revision TKA for instability based on surgical procedure. METHODS: This was a retrospective study of patients undergoing revision TKA for instability from 2015 to 2019. Patients with prior revisions were excluded. 42 patients undergoing isolated polyethylene LE without an increase in constraint were compared with 48 patients undergoing full component revision revision (FCR) of both tibial and femoral components. The primary outcome was differences in rerevision for instability. Noninstability reoperations, 90-day readmissions, and lengths-of-stay were also compared. RESULTS: LEs had a 10.1% higher rerevision for instability rate that approached statistical significance (LE 14.3% versus FCR 4.2%, P = .092). Additionally, FCR had a 4.2% rate of aseptic loosening and a 4.2% rate of periprosthetic-joint-infection, whereas LE had none (P = .181). FCR also had a longer length-of-stay (FCR 3.0 ± 1.3 versus LE: 1.8 ± 0.9 days, P < .001). No differences were found in 90-day readmissions (LE 7.1% versus FCR 4.2%, P = .661). CONCLUSION: All component revision may have a higher success rate than isolated LE in addressing instability but is associated with higher rates of surgical complications. With appropriate patient selection and risk-benefit discussion, isolated LE may be a reasonable surgical option for TKA instability with a lower complication profile and length-of-stay.

Preoperative Depression Is Associated With Increased Short-term Complications But Equivalent Long-term Outcomes in Total Knee Arthroplasty.

Concomitant depression negatively impacts outcomes following total knee arthroplasty (TKA). Patient-Reported Outcomes Measurement Information System (PROMIS) surveys are validated measures that quantify depression, pain, and physical function. We hypothesized that higher preoperative PROMIS-depression scores would be associated with inferior outcomes following TKA. A total of 258 patients underwent primary TKA at a tertiary academic center between June 2018 and August 2020. PROMIS scores were collected preoperatively and at 6 weeks, 3 months, 1 year, and 2 years postoperatively. Patients with preoperative PROMIS depression scores of 55 or greater were considered PROMIS depressed (PD) and patients with scores less than 55 were considered not PROMIS depressed (ND). The primary outcomes were changes in PROMIS scores. Secondary outcomes included total and daily mean morphine milligram equivalents (MME) received during admission as well as 90-day hospital readmission and 2-year all-cause revision rates. There were 66 (25.58%) patients in the PD group and 192 (74.42%) in the ND group. Patients in the PD group had improved depression scores at all follow-up intervals (P<.001) and decreased pain scores at 1 year (P=.016). Both groups experienced similar changes in function scores at each follow-up interval. Patients in the PD group had higher total (P=.176) and daily (P=.433) mean MME use while admitted. Ninety-day hospital readmissions were higher in the PD group (P=.002). There were no differences in 2-year revision rates (P=.648). Preoperative PROMIS-depression scores of 55 or greater do not negatively impact postoperative function, depression, or pain, and patients with these scores have greater improvement in depression and pain at certain intervals. Patients in the PD group had higher readmission rates. [Orthopedics. 2024;47(1):40-45.].

Intra-Articular Corticosteroid Injections Into a Preexisting Total Knee Arthroplasty are Associated With Increased Risk of Periprosthetic Joint Infection and Revision.

Background: This study aims to determine the risks of periprosthetic joint infection (PJI) and revision associated with injecting a preexisting total knee arthroplasty (TKA) with intra-articular corticosteroids (IACSs). Methods: The PearlDiver database was used to identify patients who underwent elective, primary TKA between 2015 and 2019. Patients who received IACS injections into the ipsilateral knee within 1 year after their primary TKA were matched 2:1 on age, gender, and Charlson comorbidity index and compared to a no-injection control group. The incidence of PJI at 1 year postoperatively and revision at 2 years postoperatively were compared between groups. Results: A total of 27,059 patients were in the injection cohort and 54,116 patients in the control cohort. The overall PJI rate was 1.3% in the injection cohort and 0.8% in the control cohort (P < .001). The rate of PJI increased with the number of post-TKA IACS injections received: 1 injection (1.3%), 2 injections (1.4%), and >3 injections (1.8%) (P < .001 for all, compared to controls). The revision rate was 3.1% in the injection cohort and 1.3% in the control cohort (P < .001). Revision rates increased with the number of post-TKA IACS injections received: 1 injection (2.5%), 2 injections (4.2%), and >3 injections (7.3%) (P < .001 for all, compared to controls). Conclusions: IACS injections into a preexisting TKA are associated with an incremental increased risk of prosthetic joint infection and revision. Considering the potential deleterious impact of PJI and complexity of revision procedures, IACS injections into a preexisting TKA should be strongly discouraged.

Revision total knee arthroplasty for arthrofibrosis improves range of motion.

PURPOSE: Arthrofibrosis after primary total knee arthroplasty (TKA) is a significant contributor to patient dissatisfaction. While treatment algorithms involve early physical therapy and manipulation under anaesthesia (MUA), some patients ultimately require revision TKA. It is unclear whether revision TKA can consistently improve these patient's range of motion (ROM). The purpose of this study was to evaluate ROM when revision TKA was performed for arthrofibrosis. METHODS: A retrospective study of 42 TKA's diagnosed with arthrofibrosis from 2013 to 2019 at a single institution with a minimum 2-year follow-up was performed. The primary outcome was ROM (flexion, extension, and total arc of motion) before and after revision TKA, and secondary outcomes included patient reported outcomes information system (PROMIS) scores. Categorical data were compared using chi-squared analysis, and paired samples t tests were performed to compare ROM at three different times: pre-primary TKA, pre-revision TKA, and post-revision TKA. A multivariable linear regression analysis was performed to assess for effect modification on total ROM. RESULTS: The patient's pre-revision mean flexion was 85.6 degrees, and mean extension was 10.1 degrees. At the time of the revision, the mean age of the cohort was 64.7 years, the average body mass index (BMI) was 29.8, and 62% were female. At a mean follow-up of 4.5 years, revision TKA significantly improved terminal flexion by 18.4 degrees (p < 0.001), terminal extension by 6.8 degrees (p = 0.007), and total arc of motion by 25.2 degrees (p < 0.001). The final ROM after revision TKA was not significantly different from the patient's pre-primary TKA ROM (p = 0.759). PROMIS physical function, depression, and pain interference scores were 39 (SD = 7.72), 49 (SD = 8.39), and 62 (SD = 7.25), respectively. CONCLUSION: Revision TKA for arthrofibrosis significantly improved ROM at a mean follow-up of 4.5 years with over 25 degrees of improvement in the total arc of motion, resulting in final ROM similar to pre-primary TKA ROM. PROMIS physical function and pain scores showed moderate dysfunction, while depression scores were within normal limits. While physical therapy and MUA remain the gold standard for the early treatment of stiffness after TKA, revision TKA can improve ROM. LEVEL OF EVIDENCE: IV.

Socioeconomic factors affecting outcomes in total knee and hip arthroplasty: a systematic review on healthcare disparities.

BACKGROUND: Recent studies showed that healthcare disparities exist in use of and outcomes after total joint arthroplasty (TJA). This systematic review was designed to evaluate the currently available evidence regarding the effect socioeconomic factors, like income, insurance type, hospital volume, and geographic location, have on utilization of and outcomes after lower extremity arthroplasty. METHODS: A comprehensive search of the literature was performed by querying the MEDLINE database using keywords such as, but not limited to, "disparities", "arthroplasty", "income", "insurance", "outcomes", and "hospital volume" in all possible combinations. Any study written in English and consisting of level of evidence I-IV published over the last 20 years was considered for inclusion. Quantitative and qualitative analyses were performed on the data. RESULTS: A total of 44 studies that met inclusion and quality criteria were included for analysis. Hospital volume is inversely correlated with complication rate after TJA. Insurance type may not be a surrogate for socioeconomic status and, instead, represent an independent prognosticator for outcomes after TJA. Patients in the lower-income brackets may have poorer access to TJA and higher readmission risk but have equivalent outcomes after TJA compared to patients in higher income brackets. Rural patients have higher utilization of TJA compared to urban patients. CONCLUSION: This systematic review shows that insurance type, socioeconomic status, hospital volume, and geographic location can have significant impact on patients' access to, utilization of, and outcomes after TJA. LEVEL OF EVIDENCE: IV.

Nonsurgical Management of Osteoarthritis of the Knee: What You Should Be Injecting Now and in the Future.

Osteoarthritis of the knee affects many Americans. With the aging of the population and increasing comorbidities (eg, obesity, diabetes, hypertension, heart disease), the use of oral or topical NSAIDs is often contraindicated. Injectable treatment options are advantageous because of the ability to decrease or avoid the unwanted systematic adverse effects of NSAIDs. Injectable treatment options for osteoarthritis of the knee go back to the 1950s, beginning with corticosteroids, which remain widely used despite concerns that they may have adverse effects on articular chondrocytes and short duration of efficacy. The recent (FDA approval in 2017) introduction of a sustained-release corticosteroid (triamcinolone acetonide extended-release) offers significantly longer benefit than standard cortisone products and with substantially lower concentration levels of chondrocyte exposure to the steroid. Hyaluronic acid was added to the options for intra-articular injection in osteoarthritis of the knee in the late 1990s and remains widely used despite some controversy over its efficacy. Although guidelines for the use of hyaluronic acid for management of osteoarthritis of the knee have varied widely, careful analysis of the data and patient's perceived efficacy indicate its continued and important role in managing osteoarthritis of the knee. Finally, the past 15 years have seen an explosion in the use of biologics including platelet-rich plasma and pluripotential (often termed stem) cells. The science behind their use and efficacy is evolving and continued study is warranted.

Race, Utilization, and Outcomes in Total Hip and Knee Arthroplasty: A Systematic Review on Health-Care Disparities.

BACKGROUND: Previous studies have shown that utilization and outcomes of total joint arthroplasty (TJA) are not equivalent across different patient cohorts. This systematic review was designed to evaluate the currently available evidence regarding the effect that patient race has, if any, on utilization and outcomes of lower-extremity arthroplasty in the United States. METHODS: A literature search of the MEDLINE database was performed using keywords such as "disparities," "arthroplasty," "race," "joint replacement," "hip," "knee," "inequities," "inequalities," "health," and "outcomes" in all possible combinations. All English-language studies with a level of evidence of I through IV published over the last 20 years were considered for inclusion. Quantitative and qualitative analyses were performed on the collected data. RESULTS: A total of 82 articles were included. There was a significantly lower utilization rate of lower-extremity TJA among Black, Hispanic, and Asian patients compared with White patients (p < 0.05). Black and Hispanic patients had lower expectations regarding postoperative outcomes and their ability to participate in various activities after surgery, and they were less likely than White patients to be familiar with the arthroplasty procedure prior to presentation to the orthopaedic surgeon (p < 0.05). Black patients had increased risks of major complications, readmissions, revisions, and discharge to institutional care after TJA compared with White patients (p < 0.05). Hispanic patients had increased risks of complications (p < 0.05) and readmissions (p < 0.0001) after TJA compared with White patients. Black and Hispanic patients reached arthroplasty with poorer preoperative functional status, and all minority patients were more likely to undergo TJA at low-quality, low-volume hospitals compared with White patients (p < 0.05). CONCLUSIONS: This systematic review shows that lower-extremity arthroplasty utilization differs by racial/ethnic group, and that some of these differences may be partly explained by patient expectations, preferences, and cultural differences. This study also shows that outcomes after lower-extremity arthroplasty differ vastly by racial/ethnic group, and that some of these differences may be driven by differences in preoperative functional status and unequal access to care. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Increased Prevalence, Complications, and Costs of Smokers Undergoing Total Knee Arthroplasty.

Given a national push toward bundled payment models, the purpose of this study was to examine the prevalence as well as the effect of smoking on early inpatient complications and cost following elective total knee arthroplasty (TKA) in the United States across multiple years. Using the nationwide inpatient sample, all primary elective TKA admissions were identified from 2012 to 2014. Patients were stratified by smoking status through a secondary diagnosis of "tobacco use disorder." Patient characteristics as well as prevalence, costs, and incidence of complications were compared. There was a significant increase in the rate of smoking in TKA from 17.9% in 2012 to 19.2% in 2014 (p < 0.0001). The highest rate was seen in patients < 45 years of age (27.3%). Hospital resource usage was significantly higher for smokers, with a length of stay of 3.3 versus 2.9 days (p < 0.0001), and hospital costs of $16,752 versus $15,653 (p < 0.0001). A multivariable logistic model adjusting for age, gender, and comorbidities showed that smokers had an increased odds ratio for myocardial infarction (5.72), cardiac arrest (4.59), stroke (4.42), inpatient mortality (4.21), pneumonia (4.01), acute renal failure (2.95), deep vein thrombosis (2.74), urinary tract infection (2.43), transfusion (1.38) and sepsis (0.65) (all p < 0.0001). Smoking is common among patients undergoing elective TKA, and its prevalence continues to rise. Smoking is associated with higher hospital costs as well as higher rates of immediate inpatient complications. These findings are critical for risk stratification, improving of bundled payment models as well as patient education, and optimization prior to surgery to reduce costs and complications.

Improved Treatment Effect of Triamcinolone Acetonide Extended-Release in Patients with Concordant Baseline Pain Scores on the Average Daily Pain and Western Ontario and McMaster Universities Osteoarthritis Index Pain Scales.

INTRODUCTION: A phase 3 randomized controlled study comparing triamcinolone acetonide extended-release (TA-ER) to conventional TA crystalline suspension (TAcs) reported variable efficacy results. Enrollment criteria may have contributed to this discrepancy, as moderate-to-severe average daily pain (ADP) was required at baseline, whereas no limitations were placed on Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC-A) pain severity. We conducted a post hoc sensitivity analysis to compare treatment effects in patients reporting moderate-to-severe osteoarthritis (OA) pain on both scales. METHODS: Participants > 40 years old with symptomatic knee OA were randomly assigned to a single intra-articular injection of TA-ER 32 mg, TAcs 40 mg, or saline-placebo and followed for 24 weeks. Patient-reported ADP, WOMAC-A, rescue medication usage, and adverse events (AEs) were assessed. Participants who reported moderate-to-severe OA pain at baseline using both instruments (ADP ≥ 5 to ≤ 9, maximum 10 and WOMAC-A ≥ 2, maximum 4) were categorized as "concordant" pain reporters; patients with baseline moderate-to-severe OA on ADP only were termed "discordant" pain reporters. RESULTS: Two-hundred-ninety-two concordant pain reporters of 484 total subjects received TA-ER 32 mg (n = 95), TAcs 40 mg (n = 100), or saline-placebo (n = 97). Baseline characteristics and AE profiles of the concordant and discordant pain responders were consistent with the full analysis population. Among concordant pain reporters, TA-ER significantly (p < 0.05) improved ADP scores vs. TAcs (weeks 5-19; area-under-the-effect [AUE]weeks1-12; AUEweeks1-24) and saline-placebo (weeks 1-20; AUEweeks1-12; AUEweeks1-24). At week 12, a higher proportion reported no knee pain (ADP = 0) with TA-ER (~ 28%) vs. TAcs (~ 8%). TA-ER significantly improved WOMAC-A vs. TAcs at weeks 4, 8, and 12, with significant reduction in rescue medication usage observed with TA-ER from weeks 2 to 20 vs. TAcs. CONCLUSIONS: In patients reporting moderate-to-severe knee OA pain at baseline based on concordant ADP and WOMAC-A scores, TA-ER provided statistically significant pain relief for ≥ 12 weeks compared with conventional TAcs. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02357459.

Osteoarthritis is a chronic condition that greatly impacts patients. Pain is the most common symptom of osteoarthritis. Clinical trials evaluating the effects of new drugs to treat osteoarthritis pain frequently use scales to rate overall pain following treatment. Patients may rate their pain using a number that best describes their pain, with the lowest number typically meaning "no pain," and the highest number typically meaning "pain as bad as you can imagine." Other rating scales may be used to rate pain in situations commonly associated with osteoarthritis.Results from a large clinical trial demonstrated that injection of an extended-release steroid significantly reduced pain compared with a conventional steroid injection on only one of the two pain-reporting scales used in the trial. A closer look found that some patients reported their pain differently on the two rating scales at the start of the trial, with some reporting moderate-to-severe pain using one questionnaire and mild pain using the other. Here, we focused on those patients who reported having moderate-to-severe osteoarthritis knee pain on both pain scales at the start and found that the pain relief benefit associated with the extended-release steroid injection was greatly improved compared with the conventional steroid injection with both measures. Patients receiving the extended-release steroid injection also decreased their use of rescue medication for pain relief.

Expanding Role of Technology in Rehabilitation After Lower-Extremity Joint Replacement: A Systematic Review.

BACKGROUND: The effectiveness of telehealth programs in the administration of rehabilitation and the monitoring of postoperative progress after joint replacement is not well studied. The purpose of the present study was to systematically review the currently available evidence on the use of smart-device technology and telehealth programs to guide and monitor postoperative rehabilitation following total joint arthroplasty and to assess their impact on outcomes following surgery. METHODS: A literature search of the MEDLINE database was performed using keywords "mobile," "app," "telehealth," "virtual," "arthroplasty," "outcomes," "joint replacement," "web based," "telemedicine," "TKA," "THA," "activity tracker," "fitness tracker," "monitor," "rehab," "online," and "stepcounter" in all possible combinations. All English studies with a level of evidence of I to III that were published from January 1, 2010, to December 19, 2020 were considered for inclusion. Quantitative and qualitative analysis was performed on the data collected. RESULTS: A total of 28 articles meeting the inclusion criteria were identified and reviewed. With regard to objective functional outcome measures, such as strength, range of motion, or results of the Timed Up and Go (TUG) test, the virtual physical therapy group had equivalent or slightly superior outcomes compared with in-person physical therapy. There was similar improvement overall in patient-reported outcome measures (PROMs) and patient satisfaction between virtual and in-person physical therapy. Virtual physical therapy resulted in cost savings ranging from $206 to $4,100 per patient compared with in-person physical therapy. CONCLUSIONS: Telerehabilitation following lower-extremity joint replacement is less expensive compared with in-person physical therapy, with equivalent outcomes and patient satisfaction. Telerehabilitation and electronic health adjuncts can be used to substitute for traditional rehabilitation and augment postoperative care following total joint arthroplasty, respectively. Telerehabilitation that provides outcomes equivalent to in-person physical therapy not only increases convenience for patients but also decreases the cost burden on the health-care system. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of total joint arthroplasty in patients with depression: A systematic review.

BACKGROUND: Depression has been implicated as a poor predictor of outcomes after total joint arthroplasty (TJA) of the lower extremity in some studies. We aimed to determine whether depression as a comorbidity affects the TJA outcomes and whether pain reduction associated with successful TJA alters depressive symptoms. METHODS: A search of PUBMED was performed using keywords "depression", "arthroplasty", "depressive disorder", and "outcomes." All English studies published over the last ten years were considered for inclusion. Quantitative and qualitative analysis was then performed on the data. RESULTS: Thirty articles met inclusion criteria (16 retrospective, 14 prospective). Three showed that depressed patients were at higher risk for readmission. Two reported that depressed patients had higher likelihood of non-home discharge after TJA compared to non-depressed patients. Four noted that depressed patients incur higher hospitalization costs than non-depressed patients. Ten suggest depression is a predictor of poor patient-reported outcome measures, pain, and satisfaction after TJA. Five suggested the gains depressed patients experience in functional outcome scores after TJA are similar to gains experienced by patients without depression. Another eight suggested that TJA improves not only function and pain but also depressive symptoms in patients with depression. CONCLUSION: The results of this review show that depression increases the risk of persistent pain, dissatisfaction, and complications after TJA. Additionally, depressed patients may incur higher costs than non-depressed patients undergoing TJA and may have worse preoperative and postoperative patient reported outcome measures (PROMs). However, the gains in function that depressed patients experience after TJA are equivalent to gains experienced by non-depressed patients and depressed patients may experience improvement in their depressive symptoms after TJA. Patient selection for TJA is critical and counseling regarding increased risk for complications is crucial in depressed patients undergoing TJA.

Outcome reporting patterns in total knee arthroplasty: A systematic review.

BACKGROUND: Total knee arthroplasty (TKA) is one of the most effective ways to treat end-stage painful conditions of the knee. However, non-standardized reporting patterns can make quantitative analysis of patient outcomes difficult. METHODS: A systematic review of the literature was performed using keywords "total knee arthroplasty" and "total knee replacement." Randomized controlled trials (RCTs) meeting the inclusion criteria were sorted and reviewed. Type of study, outcome measures used to report their results, and the actual results were recorded. Quantitative analysis was performed. RESULTS: A total of 233 RCTs were included. There was significant variability in the reporting of short term and long term outcomes in total knee arthroplasty. The most common treatment domains in order of decreasing frequency were objective knee function, subjective knee function, perioperative complications, and pain. Range of motion was the most common outcome metric reported in all the RCTs and also was the most common metric used to assess objective knee function. The most common patient reported outcome measure used to assess postoperative function was the Knee Society Score followed by Knee Injury and Osteoarthritis Outcome Score. The Visual Analog Scale was the most common measurement tool used to assess postoperative pain. Most studies assessed patient outcomes in three treatment domains. None reported outcomes in all seven domains. CONCLUSION: There is significant variability in outcome reporting patterns in TKA literature. Most studies do not track outcomes comprehensively, with a significant minority of the RCTs tracking outcomes in only one treatment domain.

Risk Factors for Mid-Flexion Instability After Total Knee Arthroplasty: A Systematic Review.

BACKGROUND: Mid-flexion instability after total knee arthroplasty (TKA) is a clinical entity that is not well studied and one that has been associated with patient dissatisfaction and inferior outcomes. We sought to provide a comprehensive review of risk factors associated with mid-flexion instability. METHODS: A comprehensive literature search of PUBMED, EMBASE, Google Scholar, and Cochrane Library was performed using keywords "mid flexion," "instability," and "knee arthroplasty" in all possible combinations. All studies published from 2010 to 2020 in English were considered for inclusion. Research design, question studied, and outcomes were recorded for each study. Quantitative and qualitative analysis was performed. RESULTS: Eighteen articles meeting inclusion criteria were identified and reviewed. There were 5 computational studies, 5 cadaveric studies, and 8 clinical studies. There were 14 different risk factors investigated in relation to mid-flexion instability after TKA: 6 implant-related, 6 technique-related, and 2 patient-related factors. Of these risk factors, 5 had contradictory results published to date, resulting in an inconclusive association with mid-flexion instability. The results of this review suggest that the effects of joint line elevation and radius-of-curvature of the femoral component on mid-flexion instability are inconclusive while articular surface conformity and preoperative joint laxity may play a bigger role than previously thought. CONCLUSION: Mid-flexion instability after TKA is a clinical entity distinct from other established forms of instability. There are patient-related, implant-related, and technique-related factors associated with mid-flexion instability. The majority of the evidence on this topic is derived from computational and cadaveric studies, underscoring the need for further clinical studies.

Outcome Reporting Patterns in Total Hip Arthroplasty: A Systematic Review of Randomized Clinical Trials.

BACKGROUND: There has been a shift toward using patient-reported outcome measures (PROMs) to capture functional improvement and patient satisfaction after total hip arthroplasty (THA). Because there is no standard measure or set of measures, variability in reporting patterns makes comparison across studies difficult. METHODS: We performed a review of the literature using the keywords "total hip arthroplasty" and "total hip replacement" to electronically search PubMed, using the date range August 1, 2014, to August 1, 2019. Randomized clinical trials (RCTs) that were published in 12 high-impact journals were analyzed. RESULTS: One hundred and fifty-nine RCTs were included. The most common topic of investigation was hip implant design and materials, followed by the effect of different hip approaches on patient outcomes. The follow-up period was classified as short-term (<2 years), mid-term (2 to 10 years), or long-term (>10 years). Only 6% of the RCTs reported long-term outcomes. The comprehensiveness of studies was determined on the basis of how many of the 7 following outcome domains were assessed: subjective hip function (PROMs), objective outcome measures (examination findings, laboratory values, etc.), imaging analysis, survivorship, patient satisfaction, pain assessment, and postoperative complications. Subjective hip function and imaging findings were the most commonly reported outcome domains, while implant survivorship and patient satisfaction were the least frequently reported. There was substantial variation in outcome reporting, with 35 unique PROMs utilized to assess subjective hip function. Although the Harris hip score was the most commonly used joint-specific PROM, it was only reported in 42% of the studies. None of the RCTs reported results in all 7 outcome domains, and 13.8% of studies reported results in only 1 outcome domain. CONCLUSIONS: There is substantial variability and a lack of comprehensiveness in outcome measures used to report results in THA clinical trials, making it nearly impossible to perform cross-study comparisons. CLINICAL RELEVANCE: There is an immediate need for the establishment of a standardized set of measures to allow comparison of outcomes across studies.

Machine Learning and Artificial Intelligence: Definitions, Applications, and Future Directions.

PURPOSE OF REVIEW: With the unprecedented advancement of data aggregation and deep learning algorithms, artificial intelligence (AI) and machine learning (ML) are poised to transform the practice of medicine. The field of orthopedics, in particular, is uniquely suited to harness the power of big data, and in doing so provide critical insight into elevating the many facets of care provided by orthopedic surgeons. The purpose of this review is to critically evaluate the recent and novel literature regarding ML in the field of orthopedics and to address its potential impact on the future of musculoskeletal care. RECENT FINDINGS: Recent literature demonstrates that the incorporation of ML into orthopedics has the potential to elevate patient care through alternative patient-specific payment models, rapidly analyze imaging modalities, and remotely monitor patients. Just as the business of medicine was once considered outside the domain of the orthopedic surgeon, we report evidence that demonstrates these emerging applications of AI warrant ownership, leverage, and application by the orthopedic surgeon to better serve their patients and deliver optimal, value-based care.