Comparison of the cost-effectiveness and safety between staged bilateral total knee arthroplasty and simultaneous bilateral total knee arthroplasty: a retrospective cohort study between 2001 and 2022.

INTRODUCTION: A substantial proportion of Hong Kong's aging population suffers from osteoarthritis in both knees. Bilateral total knee arthroplasty (BTKA) is a surgical option for addressing this condition and can be performed via two approaches: simultaneous (SimBTKA) and staged (StaBTKA) bilateral TKAs. We compared the cost-effectiveness and safety of these two methods in our institution. METHODS: We retrospectively reviewed 2,372 patients (SimBTKA, 772; StaBTKA, 1,600; female, 1,780; male, 592; mean age at SimBTKA, 70.4 ± 7.99 years; mean age at StaBTKA, 66.4 ± 7.50 years; p < 0.001) who underwent bilateral TKA in our institution from 2001 to 2022. Patients were categorized according to surgical approach. Patients undergoing BTKA in our institution were included. Particularly for SimBTKA, patients were assessed by anesthetists to be medically fit before undergoing SimBTKA according to their age, American Society of Anesthesiologists status, and osteoarthritis severity. Primary outcome was the length-of-stay (LOS) after surgery. Secondary outcomes were the 30-day unintended readmission, intensive care unit (ICU) admission, and death. RESULTS: SimBTKA had a short mean total LOS (acute hospital + rehabilitation center; SimBTKA, 13.09 days; StaBTKA, 18.12 days; p < 0.001) and mean LOS in acute hospital (SimBTKA, 7.70 days; StaBTKA, 10.42 days; p < 0.001). However, no significant difference was found in mean LOS in rehabilitation centers (SimBTKA, 5.47 days; StaBTKA, 6.32 days; p > 0.05) between the two approaches. The 30-day unintended readmission rate was low in SimBTKA (SimBTKA, 2.07%; StaBTKA, 3.30%; OR = 1.60; p > 0.05) but statistically insignificant. SimBTKA was less costly than StaBTKA by US$8,422.22. per patient. No significant differences in ICU admission and death rates were found (p > 0.05) between the two groups. CONCLUSION: SimBTKA had a shorter LOS and lower cost than StaBTKA and comparable complication rates. Therefore, SimBTKA should be indicated in medically stable patients.

Changes in the anteroposterior position of the femur relative to the tibia impact patient satisfaction in total knee arthroplasty.

BACKGROUND: In this study, we aimed to investigate the preoperative and postoperative anteroposterior position (AP) of the femur relative to the tibia in total knee arthroplasty (TKA) and assess the influence of change in the AP position on clinical outcomes. METHODS: We evaluated 49 knees that underwent bi-cruciate-substituted TKA using a navigation system. The preoperative and postoperative AP position of the femur relative to the tibia at maximum extension, 15°, 30°, 45°, 60°, 90°, 105°, and 120° and maximum flexion angles were calculated. The 2011 Knee Society Score was evaluated preoperatively and 1 year postoperatively. The Wilcoxon signed rank and Spearman's rank correlation tests were performed, with statistical significance set at P < 0.05. RESULTS: The postoperative AP position was significantly correlated with the preoperative AP position at each measured angle. The postoperative AP positions were statistically more anterior than those preoperatively. Furthermore, the changes in the AP position after TKA negatively correlated with the symptom (P = 0.027 at 30°, P = 0.0018 at 45°, P = 0.0003 at 60°, P = 0.01 at 90°, and P = 0.028 at 105°) and patient satisfaction (P = 0.018 at 60° and P = 0.009 at 90°) scores at 1 year postoperatively. CONCLUSION: The postoperative AP position of the femur relative to the tibia was strongly influenced by the preoperative those in TKA. Postoperative anterior deviation of the femur relative to the tibia from mid-flexion to deep flexion could worsen clinical outcomes.

Malnutrition in total joint arthroplasty: what should the orthopaedic surgeon consider?

Total joint arthroplasty (TJA) is rising globally, with an associated increase in associated complications, necessitating increased efforts in prevention of these complications with pre-operative optimisation. Malnutrition has been highlighted as one of the most important pre-operative modifiable risk factors to be addressed in TJA, with the term malnutrition in orthopaedic surgery having a broad definition that encompasses a wide range of nutritional abnormalities from undernutrition to overnutrition contributing to the outcomes of TJA. Complications associated with malnutrition include periprosthetic joint infection (PJI), periprosthetic fracture, dislocations, aseptic loosening, anaemia, prolonged length of stay (LOS), increased mortality, and raised health care costs. Standardised nutritional scoring tools, anthropometric measurements, and serological markers are all options available in pre-operative nutritional assessment in TJA, but there is no consensus yet regarding the standardisation of what parameters to assess and how to assess them. Abnormal parameters identified using any of the assessment methods results in the diagnosis of malnutrition, and correction of these parameters of overnutrition or undernutrition have shown to improve outcomes in TJA. With the multiple nutritional parameters contributing to the success of total joint arthroplasty, it is imperative that orthopaedic surgeon has a thorough knowledge regarding nutritional peri-operative optimisation in TJA.

Personalized total knee arthroplasty in patients with extra-articular deformities.

Over the years, with a better understanding of knee anatomy and biomechanics, superior implant designs, advanced surgical techniques, and the availability of precision tools such as robotics and navigation, a more personalized approach to total knee arthroplasty (TKA) has emerged. In the presence of extra-articular deformities, performing personalized TKA can be more challenging and specific considerations are required, since one has to deal with an acquired pathological anatomy. Performing personalized TKA surgery in patients with extra-articular deformities, the surgeon can: (1) resurface the joint, omitting the extra-articular deformity; (2) partially compensate the extra-articular deformity with intra-articular correction (hybrid technique), or (3) correct the extra-articular deformity combined with a joint resurfacing TKA (single stage or two-stage procedure). Omitting the acquired lower limb malalignment by resurfacing the knee has the advantages of respecting the joint surface anatomy and preserving soft tissue laxities. On the other hand, it maintains pathological joint load and lower limb kinematics with potentially detrimental outcomes. The hybrid technique can be performed in most cases. It circumvents complications associated with osteotomies and brings lower limb axes closer to native alignment. On the other hand, it creates some intra-articular imbalances, which may require soft tissue releases and/or constrained implants. Correcting the extra-articular deformity (through an osteotomy) in conjunction with joint resurfacing TKA represents the only true kinematic alignment technique, as it aims to reproduce native knee laxity and overall lower limb axis.

Postoperative early weight-bearing using double plating for periprosthetic, interprosthetic, and interimplant distal femur fractures following total knee arthroplasty: A report of three cases.

Background: Distal femur fractures (DFFs) following total knee arthroplasty (TKA) in older patients often require prolonged non-weight-bearing, thereby decreasing their activities of daily living (ADL) and increasing mortality. This report clarifies early weight-bearing safety and utility by using double-plate fixation on medial and lateral sides (LM180 double-plate fixation) for DFFs following TKA. Case presentation: Three cases of Su Type III periprosthetic, interprosthetic, and interimplant DFFs following TKA, where bone stock was limited, were treated with LM180 double-plate fixation using locking plates through medial and lateral incisions on the distal femur. In interprosthetic and interimplant DFF cases, the proximal section was secured by overlapping the lateral plate +/- medial plate with the proximal femur stem of the intramedullary nail by using monocortical screws and cerclage wires. Early postoperative partial weight-bearing was recommended, and full weight-bearing was allowed 4-5 weeks postoperation. All cases regained independent walking without hardware failure. Average ADL scores, namely, Barthel index (BI) and functional independence measure (FIM), were recovered to 85/100 and 114.7/126, respectively, approaching near-normal values. Conclusion: LM180 double-plate fixation for DFFs such as Su Type III periprosthetic, Vancouver type C interprosthetic, and interimplant DFFs following TKA with limited bone stock can be used to achieve early weight-bearing without fixation failure and help maintain ADL.

The effectiveness of extended reality on relieving pain after total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: Patients with total knee arthroplasty (TKA) often suffer from severe postoperative pain, which seriously hinders postoperative rehabilitation. Extended reality (XR), including virtual reality, augmented reality, and mixed reality, has been increasingly used to relieve pain after TKA. The purpose of this study was to evaluate the effectiveness of XR on relieving pain after TKA. METHODS: The electronic databases including PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and clinicaltrials.gov were searched for studies from inception to July 20, 2023. The outcomes were pain score, anxiety score, and physiological parameters related to pain. Meta-analysis was performed using the Review Manager 5.4 software. RESULTS: Overall, 11 randomized control trials (RCTs) with 887 patients were included. The pooled results showed XR had lower pain scores (SMD = - 0.31, 95% CI [- 0.46 to - 0.16], P < 0.0001) and anxiety scores (MD = - 3.95, 95% CI [- 7.76 to - 0.13], P = 0.04) than conventional methods. The subgroup analysis revealed XR had lower pain scores within 2 weeks postoperatively (SMD = - 0.49, 95% CI [- 0.76 to - 0.22], P = 0.0004) and XR had lower pain scores when applying XR combined with conventional methods (SMD = - 0.43, 95% CI [- 0.65 to - 0.20], P = 0.0002). CONCLUSION: This systematic review and meta-analysis found applying XR could significantly reduce postoperative pain and anxiety after TKA. When XR was combined with conventional methods, postoperative pain can be effectively relieved, especially within 2 weeks after the operation. XR is an effective non-pharmacological analgesia scheme.

Optimizing Tourniquet Pressure in Primary Total Knee Arthroplasty: Limb Occlusion Pressure vs Systolic Blood Pressure Method: A Randomised Controlled Study.

Background: This study aims to systematically compare the efficacy of two distinct approaches that is limb occlusion pressure (LOP) and systolic blood pressure (SBP) in determining the optimal tourniquet pressure for primary total knee arthroplasty. The overarching goal is to identify the method that yields superior outcomes in minimizing post-operative thigh pain while simultaneously reducing complications in our patient population. Methods: 311 patients scheduled for primary total knee replacement (TKR) were randomized in two groups. Group A (LOP) had 154 patients and group B had 157 patients. In group A, LOP was determined for all patients. After adding the safety margin, the tourniquet pressure was determined which was kept during the procedure. By adding 150 mm Hg to SBP in group B, the tourniquet inflation pressure was ascertained. Postoperatively, thigh pain was evaluated from day 1 to day 3 and at 6 weeks. Results: The average tourniquet pressure in group A patients having thigh circumference between 40 and 50 cm was 223.8 mm + - 19.8 mm Hg and in group B it was 262.1 + - 15.9 mm Hg (P < .01). Patients having thigh circumference between 51 and 60 cm had average tourniquet pressure of 240.07 + - 20.1 mm Hg in group A and 264.5 + - 17.4 mm Hg in group B (P < .01). The average tourniquet pressure for patients with thigh circumference more than 60 cm was 296 + /15.3 mm Hg in group A and 267.3 + /19.2 mm Hg in group B (P < 0.01). Conclusion: Tourniquet pressure determination based on the limb occlusion pressure (LOP) method provide less postoperative thigh pain and better range of motion. Graphical Abstract: Optimizing Tourniquet Pressure in Primary Total Knee Replacement: Limb Occlusion Pressure vs Systolic blood pressure method to minimize thigh pain.

Does Patellar Denervation with Electrocautery Benefits for Total Knee Arthroplasty without Patellar Resurfacing: A Meta-analysis of Randomized Controlled Trails.

To investigate the effects of patellar denervation (PD) and non-patellar denervation (NPD) after primary total knee arthroplasty (TKA) without patellar resurfacing, this study conducted systematic electronic searches in November 2023 using PubMed, Embase, Web of Science, Cochrane, and Scopus, adhering to Cochrane Collaboration recommendations. Only randomized controlled trials (RCTs) were included. Additionally, a manual search was performed to identify potentially eligible studies from the reference lists of review articles. Two researchers independently conducted literature reviews, data extraction, and risk of bias assessments. The outcome analysis encompassed the incidence of anterior knee pain (AKP), visual analogue scale (VAS), range of motion (ROM), American Knee Society Score (KSS), Oxford Knee Score (OKS), patellar score (PS), complications, and reoperations. Meta-analysis was executed using RevMan 5.3 software. To enhance the credibility of the study, TSA v0.9 software was utilized to perform power analysis on the overall efficacy of primary and secondary outcomes. Twelve studies involving 1745 patients (1587 knees) were included, with 852 undergoing PD and 893 undergoing NPD. Results indicated a superior reduction in AKP incidence in the PD group compared to the NPD group. Statistically significant differences were observed between PD and NPD in KSS, OKS, and PS. However, the upper limit of the 95% confidence interval for each outcome fell below the minimal clinically important difference (MCID). No significant differences were found in VAS and ROM between PD and NPD. Additionally, PD was not associated with an increased incidence of complications or reoperations. Within 12 months and beyond, PD was proven to be a beneficial intervention in reducing AKP following TKA without patellar resurfacing, achieved without an increase in complications or reoperations. Regarding KSS, OKS, and PS, the minimal advantage achievable through PD may not be clinically significant.

Component rotational mismatch in the standing position is a potential risk factor for unfavourable functional outcomes after total knee arthroplasty.

Purpose: This study assessed rotational mismatch between components after total knee arthroplasty (TKA) in the supine and standing positions and aimed to investigate the effect of rotational mismatch in the standing position on postoperative patient-reported outcome measures (PROMs). Methods: Seventy-one patients (71 knees) who underwent TKA for medial knee osteoarthritis were used to investigate rotational mismatches between components. Rotational mismatches between components were examined on postoperative standing whole-leg and supine knee radiographs using a three-dimensional-to-two-dimensional model image registration technique, and the angles between the reference axes of the components were measured. Component alignment was evaluated using postoperative computed tomography images, and a questionnaire (2011 version of the Knee Society Score: [KSS 2011]) was mailed to investigate postoperative PROMs. Results: In the entire cohort, rotational mismatches in the supine and standing positions were similar (p = 0.9315). In 15% of patients, the mismatch was large (>5°) in the supine position but small (<5°) in the standing position (overestimated group). However, in 23% of patients, the mismatch was small (<5°) in the supine position and large (>5°) in the standing position (underestimated group). The underestimated group had severe preoperative varus deformity, resulting in external rotation of both femoral and tibial components. Rotational mismatch in the standing position (p = 0.0032) was a significant risk factor for unfavourable PROMs. Patients with a mismatch in the standing position had significantly lower scores than those without a mismatch (p = 0.0215), exceeding the minimal clinically important difference values. Conclusions: The underestimated group is clinically important because the surgical procedure and intraoperative assessment of component placement are performed in the supine position. In cases of severe preoperative varus deformity, care should be taken not to place the component in malrotation to avoid rotational mismatch in the standing position. Level of Evidence: Ⅳ, Case series.

Are short term outcomes superior following total knee arthroplasty when infra-patellar fat pad is resected? A systematic review and meta-analysis.

BACKGROUND: Data suggests the infra-patellar fat pad (IPFP) is resected in the majority of total knee arthroplasty cases. Current literature suggests there may be scope for increasing preservations rates. A systematic review and meta-analysis of available literature was performed to assess if resection of IPFP resulted in superior patient outcomes. METHODS: Scopus, PubMed, Cochrane, Embase and CINAHL were systematically searched in February 2024 for articles of relevance and meta-analysis conducted. A standardized mean difference and confidence interval of 95% was calculated. An odds ratio was calculated for all included datasets. Heterogeneity was assessed for using the I2 statistic. RESULTS: Thirteen studies were included within this review. IPFP resection shortened the patella tendon at 6 months post-operatively (OR, 0.07; 95% CI, 0.02-0.12, P = 0.006). Results favoured preservation at 12 months post-operatively (OR, 0.02; 95% CI, -0.02 to 0.06, P = 0.32). Oxford Knee Society (OKS) results statistically favoured preservation at 6 months (OR, 1.57; 95% CI, 0.74-2.39, P = 0.0002). Findings at 12 months favoured resection (OR, -0.49; 95% CI, -5.39, 4.41, P = 0.84). Resection increased anterior knee pain at 6-12 months post-operatively (OR, 1.45; 95% CI, 1.12-1.89, P = 0.005). Combined subgroup analysis of flexion favoured resection (OR, -2.15; 95% CI, -6.52 to 2.22, P = 0.34). CONCLUSION: OKS and patella tendon length results favoured preservation at 6 months however did not reach minimal clinically important difference. Combined subgroup analysis of flexion did not yield a statistically significant result. Rates of anterior knee pain at 6-12 months favoured preservation.

Mechanically aligned total knee arthroplasty does not yield uniform outcomes across all coronal plane alignment of the knee (CPAK) phenotypes.

PURPOSE: Patient dissatisfaction rates following total knee arthroplasty (TKA) reported in the literature reach 20%. The optimal coronal alignment is still under debate. The aim of this retrospective study was to compare clinical outcomes in different coronal plane alignment of the knee (CPAK) phenotypes undergoing mechanically aligned (MA) TKA. The hypothesis was that knees with preoperative varus arithmetic hip-knee-ankle angle (aHKA) would achieve inferior clinical outcomes after surgery compared to other aHKA categories. Additionally, another objective was to assess CPAK phenotypes distribution in the study population. METHODS: A retrospective selection was made of 180 patients who underwent MA TKA from April 2021 to December 2022, with a 1-year follow-up. Coronal knee alignment was classified according to the CPAK classification. Clinical outcome evaluations were measured using the Knee Society Score (KSS), Oxford Knee Score (OKS), Short Form Survey 12 and Forgotten Joint Score (FJS). Differences in clinical outcomes were considered statistically significant with a p value <0 .05. RESULTS: Patients with varus aHKA achieved significantly inferior outcomes at final follow-up compared to other aHKA categories in KSS pt. 1 (79.7 ± 17.2 vs. 85.6 ± 14.7; p = 0.028), OKS (39.2 ± 9.2 vs. 42.2 ± 7.2; p = 0.019) and FJS (75.4 ± 31.0 vs. 87.4 ± 22.9; p =0 .003). The most common aHKA category was the varus category (39%). The most common CPAK phenotypes were apex distal Types I (23.9%), II (22.8%) and III (13.3%). CONCLUSION: MA TKA does not yield uniform outcomes across all CPAK phenotypes. Varus aHKA category shows significantly inferior results at final follow-up. The most prevalent CPAK categories are varus aHKA and apex distal JLO, with phenotypes I, II and III being the most common. However, their gender distribution varies significantly. LEVEL OF EVIDENCE: Level IV.

Effectiveness of the transitional care model in total knee arthroplasty patients: A randomized controlled trial.

AIM: This study has aimed to assess the effectiveness of the transitional care model (TCM) on functional status, perceived self-efficacy and healthcare utilization in patients undergoing total knee arthroplasty (TKA). METHOD: This randomized controlled study was conducted between February and November 2021 in a public hospital. The study randomly assigned patients to either a 6-week 'TCM' program or usual care. The sample size was n = 70, with each group comprising 35 individuals. Patient outcomes, including self-efficacy, functional status and healthcare service readmission rates, were monitored for TKA patients. RESULTS: Nursing care based on the 'TCM' was found to enhance functional status and increase the level of self-efficacy among TKA patients, leading to a decrease in healthcare service readmissions. CONCLUSIONS: The study recommends preparing patients and their families for the preoperative and postoperative processes. It emphasizes the importance of providing necessary training and consultancy services under the leadership of orthopaedic nurses responsible for TKA patient care, guided by the principles of TCM.

Optimizing Total Knee Arthroplasty Rehabilitation with Telehealth Physical Activity Behavior Change Intervention: A Randomized Clinical Trial.

OBJECTIVE: Conventional total knee arthroplasty (TKA) rehabilitation has little impact on sedentary lifestyles that have negative long-term health consequences. The purpose of this trial was to determine the effect of telehealth-based physical activity behavior change intervention on physical activity and functional outcomes following TKA. METHODS: This study was a 2-arm, parallel randomized controlled superiority trial at a regional Veterans Affairs medical center. The participants were 92 US military Veterans (mean age = 65.7 [SD =7.8] y) undergoing unilateral TKA. The Physical Activity Behavior Change (PABC) intervention included telehealth-based self-management training (ten 30-minute sessions) delivered over 12 weeks. The control intervention included telehealth-based health education sessions that matched PABC frequency and duration. Both groups participated in standardized conventional outpatient rehabilitation. Physical activity, measured as average daily step count, was the primary outcome. Secondary outcomes were Life-Space Assessment questionnaire, 30-Second Chair-Stand test, Timed Up-and-Go Test, Six-Minute Walk test, Western Ontario and McMaster Universities Osteoarthritis Index, and Veterans RAND 12-Item Health Survey. The Self Efficacy for Exercise scale and daily time spent in different postures (sitting/lying, standing, stepping) were exploratory variables. Outcomes were measured at baseline (before surgery), mid-intervention (8 weeks after surgery), after the intervention (14 weeks after surgery; primary endpoint), and follow-up (38 weeks after surgery). RESULTS: The PABC group had an estimated 931 (95% CI = 42-1819) more daily steps than the control group from baseline to 14 weeks, though a between-group effect was not sustained at 38 weeks. There were no group differences in secondary outcomes. Participants included only military veterans using Veteran's Health Administration services. The intervention targeted self-management and did not include peer support. CONCLUSIONS: The PABC intervention improved physical activity for Veterans recovering from unilateral TKA at 14 weeks after surgery, though the effect was not sustained at 38 weeks. Physical function improved with rehabilitation but was not different between groups, indicating that physical function was not a primary driver of physical activity behavior. IMPACT: Conventional TKA rehabilitation has a negligible effect on free-living physical activity, which is relevant to long-term health outcomes. This trial identified telehealth physical activity self-management as effective in addressing activity behaviors, separate from conventional rehabilitation strategies.

High Demand for Psychological Support in Patients Who Have Periprosthetic Hip and Knee Joint Infections: An Analysis of 13,976 Patients.

BACKGROUND: There is only sparse knowledge on the psychological burden of patients who have periprosthetic joint infections (PJI). The aim of our study was to assess the need for psychological support following total joint arthroplasty of the hip and knee. A special focus was set on patients who had aseptic and septic complications. METHODS: A total of 13,976 patients who underwent total hip (THA, n = 6,926) or total knee arthroplasty (TKA, n = 7,050) between January 1st, 2012 and December 31st, 2019 at a single institution were retrospectively evaluated for the postoperative need for a psychological consultation. Data was collected on age, sex, type of surgery, and indications for revision procedures. The need for a psychological consultation was assessed during the daily postoperative visits, which were further coordinated by two institutional psychologists. RESULTS: The average age was 68 years (range, 12 to 100), and there were 63.5% women. The overall rate of psychological consultations was 1.7%. Patients who had a septic indication for revision surgery had an 18.7-fold higher rate of postoperative psychological consultations compared to patients following primary surgery and a 5.4-fold higher rate compared to patients who had an aseptic indication. In detail, this rate was 1.0% in the primary subgroup, compared to 7.7% following revision arthroplasty (P < 0.001). In the revision subgroup, the rate was 17.9% for septic and 3.3% for aseptic revision arthroplasty cases (P < 0.001). Postoperative psychological consultations were twice as frequent in women (2.1%) compared to men (1.0%), P < 0.001. CONCLUSIONS: The present study raises awareness of the markedly high psychological burden in revision arthroplasty cases, in the view of the high estimated number of unknown cases. There is a significant correlation between PJI and the postoperative need for a psychological consultation, with women being at an even higher risk. Health care providers should aim at offering psychological support for patients who have a septic complication, with affected patients being at risk for psychological stress.

A Pilot Study on the Efficacy of an App-Based Rehabilitation Counselling Program after Total Knee Arthroplasty.

The aim of this study was to determine the effects of a novel app-based rehabilitation counselling program in patients recovering from total knee arthroplasty. In the app-based rehabilitation counselling program, a counselor provides one-on-one rehabilitation exercises and management-focused psychological counselling after total knee arthroplasty (TKA). This study included 42 patients, who were divided into three groups of 14 patients each: Group A, whose rehabilitation training was based on a guideline leaflet; Group B, whose rehabilitation was based on the app-based rehabilitation counselling program; and Group C, whose rehabilitation training was based on continuous passive motion combined with the app-based rehabilitation counselling program. To determine the effects of rehabilitation, the isokinetic knee muscle strength and knee joint range of motion were measured in addition to knee function tests such as the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the visual analogue scale (VAS) for pain at two and three months after rehabilitation. The comparison of the means of the three groups was analyzed using one-way analysis of variance (ANOVA), with Group C showing significant variance in isokinetic knee muscle strength (p < 0.05), passive ROM (p < 0.01), and WOMAC (p < 0.05) after three months. As a result, this study confirmed the positive potential of the app-based rehabilitation counselling program.

Periprosthetic Joint Infections of the Knee-Comparison of Different Treatment Algorithms.

Background: Periprosthetic joint infection (PJI) following total knee arthroplasty is a serious complication lacking evidence-based diagnostic and treatment protocols, particularly in ruling out persisting infection before reimplantation. Methods: This retrospective analysis assessed the mid-term outcomes of 66 patients undergoing septic two-stage knee revision surgeries from 2007 to 2013, diagnosed as per the Musculoskeletal Infection Society criteria. After implant removal and antibiotic treatment, reimplantation decisions were based on either joint aspiration, blood counts, and clinical examination (group A) or an open biopsy (group B). Both groups underwent meticulous debridement and spacer exchange during the interim period. Results: Late re-infection occurred in 12.1% of all patients. In group A, 13.8% experienced late re-infection, with 14.3% in subgroup A1 and 13.3% in subgroup A2. In group B, 10% had a late re-infection. No significant difference in re-infection or complication rates was found between the groups. Conclusions: The study did not demonstrate the superiority of group B's approach of open biopsy over group A's joint aspiration, clinical examination, and blood counts in preventing re-infection or reducing complications.

Time to Total Knee Arthroplasty (TKA) Post Intra-Articular Injection.

Background: Disease-modifying treatments are not currently developed to target the underlying causes of knee osteoarthritis (KOA). Corticosteroids (CS), hyaluronic acid (HA), and platelet-rich plasma (PRP) intra-articular (IA) injections are commonly used for patients that do not respond to non-pharmacological treatments, oral nonsteroidal anti-inflammatory, or pain medications to address solely KOA symptoms. Utilizing TKA as an endpoint in the KOA disease progression provides a basis to determine efficacy of this treatment pathway. The primary objective is to evaluate a large national database to determine the time between first injection and total knee arthroplasty in patients solely administered intra-articular IA, CS, and HA. Methods: A retrospective query was performed on a national, all-payer claims database (PearlDiver, Colorado Springs, CO, USA), a composite of over 160 million Health Insurance Portability and Accountability Act compliant orthopedic records across all states and territories of the United States spanning 2016 to 2022. The database was queried to produce three distinct cohorts for analysis (PRP, HA, and CS). A 4:1 case match was conducted to compare cohorts receiving a subsequent TKA. Kaplan-Meier survival analysis analyzed the TKA-free survival of patients within each group at 6 months and 1 to 4 years. The log-rank test was performed for comparisons between survival cohorts. Results: The PRP cohort had a total population of 3240 patients, of which 71 (2.2%) received a subsequent TKA. The corticosteroid cohort had a total population of 1,382,572, of which 81,271 (5.9%) received a subsequent TKA. The HA cohort had a total population of 164,000, of which 13,044 (8.0%) received a subsequent TKA. Due to the low population within the PRP group, this group was excluded from comparison. The mean time to TKA from first injection in the HA group was 377.8 days, while in the corticosteroid group it was 370.0 days. The proportions of TKA-free survival for CS and HA when compared at 4 years post-injection was similar between groups (p = 0.05). Discussion and Conclusion: Patients that received only IA-corticosteroids or IA-hyaluronic acid had a similar length of time between the first injection and the total knee arthroplasty associated with the injected joint. This evidence provides information for clinicians and patients alike when contemplating these non-surgical injection modalities for KOA. The similarity observed between these treatments supports the need for future research to determine whether there is any potential for reduction in healthcare costs for KOA treatment prior to TKA.

Comparing Complication Rates, Costs, and Length of Stay between Unicompartmental and Total Knee Arthroplasty: Insights from a Big Data Analysis Using the National Inpatient Sample Dataset.

Background: Unicompartmental knee arthroplasty (UKA) is increasingly used for knee osteoarthritis due to faster recovery, better range of motion, and lower costs compared to total knee arthroplasty (TKA). While TKA may offer longer-lasting results with lower revision rates, this study compares the relative benefits and limitations of UKA and TKA using the National Inpatient Sample (NIS) database. Methods: This retrospective analysis examined outcomes of elective UKA and TKA procedures from 2016 to 2019, identifying 2,606,925 patients via ICD-10 codes. Propensity score matching based on demographics, hospital characteristics, and comorbidities resulted in a balanced cohort of 136,890 patients. The present study compared in-hospital mortality, length of stay, postoperative complications, and hospitalization costs. Results: The results showed that UKA procedures increased significantly over the study period. Patients undergoing UKA were generally younger with fewer comorbidities. After matching, both groups had low in-hospital mortality (0.015%). UKA patients had shorter hospital stays (1.53 vs. 2.47 days) and lower costs (USD 55,976 vs. USD 61,513) compared to TKA patients. UKA patients had slightly higher rates of intraoperative fracture and pulmonary edema, while TKA patients had higher risks of blood transfusion, anemia, coronary artery disease, pulmonary embolism, pneumonia, and acute kidney injury. Conclusions: UKA appears to be a less-invasive, cost-effective option for younger patients with localized knee osteoarthritis.

Is asymptomatic bacteriuria a noticeable risk factor for periprosthetic joint infection following total joint arthroplasty? A systematic review and meta-analysis.

INTRODUCTION: Total joint arthroplasty (TJA) is a common procedure that improves the quality of life for severe arthritis patients. The rising demand for TJA places enormous financial strain on the world's healthcare systems, which is exacerbated by postoperative readmissions for complications such as periprosthetic joint infections (PJIs). We conducted a systematic review and meta-analysis to determine if asymptomatic bacteriuria (ASB) increases infection risk. METHODS: We conducted searches in three databases: PubMed, Scopus, and Web of Science. Screening steps have been carried out according to PRISMA guidelines. The study focused on patients who had undergone TJA and exhibited ASB. Two reviewers independently screened, assessed quality, and extracted data. Meta-analysis used Mantel-Haenszel method. RESULTS: Following full-text screening, 12 studies were deemed eligible for inclusion in the systematic review, encompassing a total of 42,592 patients. A heightened occurrence of PJI was observed among TJA patients with ASB in comparison to controls (OR [95%CI] = 3.47 [1.42-8.44]). However, microorganisms responsible for the PJIs differed from those identified in the urine cultures of ASB. Additionally, analyses indicate that preoperative antibiotic treatment for ASB does not significantly affect the subsequent risk of PJI (OR [95% CI] = 1.00 [0.42-2.39]). Unlike surgical site infection (SSI), which did not show a difference in the rate of occurrence between the two groups, TJA patients with ASB were more likely to experience superficial wound infection (OR [95%CI] = 3.81 [2.02-7.21]). CONCLUSION: This review and meta-analysis confirm that ASB correlate with heightened risks of PJI and superficial infection in TJA patients. However, no relationship was found between ASB and PJI microorganisms which raise doubts about the role of ASB microorganisms as the direct cause of infection following TJA.

Intra- and inter-operator reliability of three-dimensional preoperative planning in total knee arthroplasty.

PURPOSE: To characterize the intra- and inter-operator reliability of a CT-based 3D preoperative planning software. MATERIALS AND METHODS: This study analyzed 30 CT scans of de-identified knees with osteoarthritis. For each scan, a case planner segmented the bones and pre-planned the TKA. Three orthopedic surgeons then reviewed each pre-planning three times at least one week apart, in a blinded manner. During the reviews, the surgeons modified the pre-plannings until they felt the plannings matched the objectives defined collegially at the beginning of the study. Reliability was assessed using the Intraclass Correlation Coefficient (ICC) and the Standard Error of Measurement (SEM). RESULTS: The intra- and inter-operator reliabilities for implant size selection were almost perfect (ICC between 0.97 and 0.99). Implants of same sizes were selected in 67.1-90.0% of cases. For implant placements, almost perfect intra- and inter-operator reliability was observed in all degrees-of-freedom (ICC between 0.81 and 1.00), except in flexion-extension for the femur (intra-operator ICC between: 0.76 and 0.99; inter-operator ICC of 0.61) and the tibia (intra-operator ICC between 0.12 and 1.00; inter-operator ICC of 0.03). All implant placements SEM were below 1.3 mm or 1.7°. CONCLUSIONS: This study showed high intra- and inter-operator reliability for implant size selection and, in most of the degrees-of-freedom, also for implant placements. Further research is needed to evaluate the benefit of developing more precise means of describing the objectives of the surgical planning as well as to evaluate the possibility and relevance of adding features in the planning software to assist the operators.