Neuromuscular Electrical Stimulation Use after Total Knee Arthroplasty Improves Early Return to Function: A Randomized Trial.

Neuromuscular electrical stimulation (NMES) has been reported as an effective method for quadriceps strengthening which could attenuate muscle loss in the early total knee arthroplasty (TKA) postoperative recovery period. The purpose of this randomized controlled trial was to test whether postoperative use of NMES on TKA patients results in increased quadriceps strength and ultimately improved functional outcomes. This randomized controlled clinical trial of 66 primary TKA patients was conducted at a large academic medical center. Patients were randomized 2:1 into treatment (NMES use, n = 44) or control arm (no NMES, n = 22). Patients who used the device for an average of 200 minutes/week or more (starting 1 week postoperative and continuing through week 12) were considered compliant. Baseline measurements and outcomes were recorded at 3, 6, and 12 weeks postoperatively, and included quadriceps strength, range of motion (ROM), resting pain, functional timed up and go (TUG), stair climb test, and knee injury and osteoarthritis outcome score (KOOS) and veterans rand 12-item health survey (VR-12) scores. Patients in the treatment arm (NMES use) experienced quadriceps strength gains over baseline at 3, 6, and 12 weeks following surgery, which were statistically significant compared with controls with quadriceps strength losses at 3 (p = 0.050) and 6 weeks (p = 0.015). The TUG improvements for patients treated with NMES showed significant improvements at 6 (p = 0.018) and 12 weeks (p = 0.003) postoperatively. Use of a home-based application-controlled NMES therapy system added to standard of care treatment showed statistically significant improvements in quadriceps strength and TUG following TKA, supporting a quicker return to function.

Malnutrition increases the 30-day complication and re-operation rates in hip fracture patients treated with total hip arthroplasty.

INTRODUCTION: This study sought to determine the effect that malnutrition, defined as hypoalbuminemia, has on hip fracture patients treated with total hip arthroplasty (THA). Specifically, we evaluated: (1) demographics and perioperative data; (2) postoperative complications; and (3) re-operation rates. METHODS: The National Surgical Quality Improvement Program database was utilised to identify hip fracture patients who underwent THA from 2008 to 2015. Propensity scores were calculated for the likelihood of having a preoperative albumin measurement. Hip fracture patients who underwent THA and had preoperative hypoalbuminemia (<3.5 g/dL) (n = 569) were compared to those who had normal albumin levels (⩾3.5 g/dL) (n = 1098) in terms of demographics and perioperative data. Regression models were adjusted for age, sex, modified Charlson/Deyo scores, and propensity scores to evaluate complication and re-operation rates. RESULTS: Compared to controls, hypoalbuminemia patients were older (p = 0.006), more likely male (p = 0.024), had higher Charlson/Deyo scores (p = 0.0001), more likely smokers (p < 0.0001), more likely functionally dependent (p < 0.0001), had ASA scores ⩾3 (p < 0.0001) and had longer LOS (p < 0.0001). Compared to controls, hypoalbuminemia patients had 80% higher risk for any complication (OR = 1.80; 95% CI, 1.43-2.26), 113% higher risk for major complications (OR = 2.13; 95% CI, 1.31-3.48), and 79% higher risk for minor complications (OR = 1.79; 95% CI, 1.42-2.26), and 97% increased risk for re-operation (OR = 1.97; 95% CI, 1.20-3.23). CONCLUSIONS: The findings in the present study indicate the need to develop better pre- and postoperative medical and nutritional care for malnourished hip fracture patients who undergo THA in order to potentially mitigate their increased risk.

Total Joint Arthroplasty Outcomes in Patients With a Previously Failed Toxicology Screen: A Propensity Score-Matched Analysis.

BACKGROUND: The purpose of this study is to review the outcomes of a consecutive series of arthroplasty patients who had previously failed a urine toxicology test. Specifically, we assessed (1) mortality at last follow-up; (2) 90-day readmission and reoperation; (3) rate of complications; and (4) hospital length of stay (LOS) and rates of nonhome discharge. METHODS: A single-institution, electronic medical record database was queried for primary arthroplasty patients from 2006 to 2017 who had previously failed a day-of-arthroplasty urine toxicology screen. Patients were matched in a 2:1 ratio with toxicology-negative controls. RESULTS: The mortality rate among toxicology-positive THA patients was 1 of 20 (5%) compared to 0 of 40 among controls (P = .333); the rate of readmission was 3 of 20 (15%) vs 0 of 40 (P = .033); the rate of reoperation was 1 of 20 vs 0 of 40 (P = .333); the rate of surgical complications was 6 of 20 (30%) vs 1 of 40 (2.5%) (P = .004); the rate of medical complication was 4 of 20 (20%) vs 1 of 40 (2.5%) (P = .038); the average LOS was 4 days (range, 1-8 days) vs 2 days (range, 1-10) (P = .002); and the rate of nonhome discharge was 5 of 20 (25%) vs 2 of 40 (5%) patients in the control group (P = .013). The mortality rate among toxicology-positive TKA patients was 1 of 19 (5.3%) compared to 0 of 38 among controls (P = .333); the rate of readmission was 5 of 19 (26.3%) vs 2 of 39 (5.3%) (P = .033); the rate of reoperation was 3 of 19 (15.8%) vs zero (P = .033); the rate of surgical complications was 4 of 21 (21.1%) vs 1 of 38 (2.6%) (P = .038); the rate of medical complications was 5 of 19 (26.3%) vs 2 of 38 (5.3%) (P = .035); the average LOS was 4 days (range, 2-6 days) vs 2 days (range, 1-8 days) (P = .001), the rate of nonhome discharge was 7 of 19 (36.8%) compared to 2 of 38 (5.3%) in the control group (P = .004). CONCLUSION: These results suggest that toxicology-positive patients require a careful discussion of goals of care before undertaking total hip arthroplasty or total knee arthroplasty.

Quadriceps tendinopathy: a review-part 1: epidemiology and diagnosis.

Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Historically, they have been labeled as Jumper's knee due to the high prevalence seen in the athletic community. In many published reports, the name "patellar tendinopathy" is used to describe this disorder of the quadriceps tendon at the patellar insertion, and the names are often used interchangeably. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the first part we review: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In the second part we discuss: (I) classification; (II) prognosis; and (III) treatment results.

Quadriceps tendinopathy: a review, part 2-classification, prognosis, and treatment.

Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy in the non-athlete population. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the previous part we reviewed: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In this part we discuss: (I) classification; (II) prognosis; and (III) treatment results.

Chronic Obstructive Pulmonary Disease Is Associated With Short-Term Complications Following Total Knee Arthroplasty.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a major global health issue and a leading cause of morbidity and mortality. Patients with COPD are at increased risk of complications following surgery. The purpose of this study is to evaluate the postoperative total knee arthroplasty (TKA) outcomes in these patients in comparison to a non-COPD matching cohort. Specifically, we asked the following questions: (1) "Is COPD associated with adverse perioperative outcomes?" and (2) "Does COPD increase the risk of short-term complications following TKA?" METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 111,168 patients who underwent TKA between 2008 and 2014. A total of 3975 patients with COPD were identified. Both COPD and non-COPD cohorts were compared in terms of the following outcomes: hospital length of stay, discharge disposition, and 30-day postoperative complications. RESULTS: COPD was a predictor for a prolonged length of stay and a discharge to an extended care facility (P < .001). They were at significantly increased risk of any complication including increased mortality, pneumonia, reintubation, use of a mechanical ventilator for >48 hours, cardiac arrest, progressive renal insufficiency, deep infection, return to operating room, and a readmission within 30 days postoperatively. CONCLUSION: Patients with COPD are more likely to experience postoperative complications following TKA when compared to non-COPD patients. Pulmonary evaluation and optimization are crucial to minimize adverse events from occurring in this difficult-to-treat population.

Chronic Obstructive Pulmonary Disease Is Associated With Short-Term Complications Following Total Hip Arthroplasty.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality. Furthermore, COPD patients are at increased risk of complications following surgery. The purpose of this study was to evaluate the postoperative total hip arthroplasty (THA) outcomes of COPD patients. Specifically, we asked the following questions: (1) Is COPD associated with adverse perioperative outcomes and (2) Does COPD increase the risk of short-term complications following THA? METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify 64,796 patients who underwent THA between 2008 and 2014. A total of 2426 patients with COPD were identified. COPD and non-COPD cohorts were compared based on the following outcomes: hospital length-of-stay, operative times, discharge disposition, and 30-day postoperative complications. RESULTS: COPD patients were found to have a longer length-of-stay and be discharged to an extended care facility (P < .001). COPD patients were also at significantly (P < .05) increased risk for any complication, such as mortality, myocardial infarction, pneumonia, septic shock, unplanned reintubation, use of a mechanical ventilator >48 hours, deep infection, require a blood transfusion, return to operating room, and a readmission within 30 days postoperatively. CONCLUSIONS: COPD patients are more likely to suffer from postoperative complications following THA when compared to non-COPD patients. Many of these complications are medical, pulmonary evaluation and medical optimization are a critical step in preoperative management for these patients.

Does gender influence how patients rate their patient experience after total hip arthroplasty?

BACKGROUND: Patient satisfaction, as measured by Press Ganey (PG) surveys, partially determines reimbursement rates. Knowing what influences these scores can lead to higher reimbursement for total hip arthroplasty (THA) surgeons. Currently, it is unknown whether gender biases exist in satisfaction surveys post-THA. Therefore, we asked: (i) which PG survey factors most influence hospital ratings among men and women after THA; and (ii) is there a difference in survey element responses and overall hospital ratings between men and women post-THA? METHODS: We queried the PG database for patients who underwent THA from November 2009 to January 2015, which yielded 692 patients (277 men, 415 women). Weighted means were analysed for the scores of PG domains between men and women. A multiple regression analysis was performed for each gender, with overall hospital satisfaction as the dependent variable, in order to assess the influence (ß-weight) of each PG domain. RESULTS: For men, pain management (ß = 0.317, p = 0.021) most influenced overall hospital rating. For women, staff responsiveness (ß = 0.451, p<0.001) most influenced overall hospital rating. This was followed by communication with nurses (ß = 0.373, p<0.001), and doctors (ß = 0.236, p = 0.002). There were no significant differences in mean overall hospital rating between groups. CONCLUSIONS: It is advantageous for orthopaedic surgeons to focus on the PG domains most pertinent to each patient gender post-THA. Focusing efforts based on gender may allow for better patient satisfaction, optimised reimbursements, and improved hospital ratings.

Manufactured Brace Modalities for Elbow Stiffness.

Multiple surgical and nonsurgical treatment options exist for patients with elbow stiffness. Many nonsurgical mobilization bracing options have been implemented to increase elbow range of motion. Three of the main bracing options for these patients are turnbuckle, static progressive stretch, and dynamic bracing. The purpose of this study was to review the current literature on turnbuckle, static progressive stretch, and dynamic bracing to provide information for practitioners and patients regarding which brace is more appropriate to use for elbow stiffness. Specifically, the authors compared the protocol and duration of splint use and changes in range of motion outcomes between static progressive and dynamic brace cohorts. A search of PubMed yielded 8 studies meeting inclusion criteria. Overall, although all 3 bracing options are available for patients, these studies found that, based on the evaluated metrics, the static progressive brace was a markedly superior option for patients with elbow stiffness. The time required to wear the static progressive stretch brace was 13 times less than that for the turnbuckle and 5 times less than that for the dynamic devices. Additionally, the high failure rate (10%) and low success rate (29%) of the dynamic brace, compared with the 63% regaining of functional range of motion in the static progressive stretch group, further highlight the benefits of the static progressive stretch brace. [Orthopedics. 2018; 41(1):e127-e135.].

Performance of implant sonication culture for the diagnosis of periprosthetic shoulder infection.

BACKGROUND: Diagnosing infection after shoulder arthroplasty can be a challenge because of the high prevalence of low-virulence organisms, such as Propionibacterium acnes. The purpose of this study was to evaluate the utility of implant sonication fluid cultures in the diagnosis of periprosthetic joint infection compared with standard culture techniques in patients undergoing revision shoulder arthroplasty. METHODS: Routine perioperative testing was performed in 53 patients who underwent revision shoulder arthroplasty. In addition to routine tissue and fluid culture, the retrieved shoulder implants underwent sonication with culture of the sonicate fluid. Diagnostic performance of implant sonication culture was determined on the basis of previously defined infection criteria and compared with standard intraoperative cultures. RESULTS: Of the 53 revision cases that underwent implant sonication fluid culture, 25 (47%) were classified as infected. Intraoperative culture (tissue and fluid) sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 96%, 75%, 77%, 95%, and 85%, respectively. Using a cutoff of >20 colony-forming units per milliliter to exclude contaminants, the sensitivity, specificity, PPV, NPV, and accuracy of implant sonicate culture were 56% (P < .001, compared with standard intraoperative cultures), 93% (P = .07), 88% (P = .4), 70% (P = .02), and 75% (P = .22), respectively. Without use of a sonication fluid culture cutoff value, the sensitivity, specificity, PPV, NPV, and accuracy of implant sonicate culture were 96% (P = 1.0, compared with standard intraoperative cultures), 64% (P = .38), 71% (P = .53), 95% (P = .9), and 79% (P = .45). CONCLUSIONS: Implant sonication fluid culture in revision shoulder arthroplasty showed no significant benefits over standard intraoperative cultures in diagnostic utility for periprosthetic joint infection.

Use of an App-Controlled Neuromuscular Electrical Stimulation System for Improved Self-Management of Knee Conditions and Reduced Costs.

Patients suffering from quadriceps muscle weakness secondary to osteoarthritis or after surgeries, such as total knee arthroplasty, appear to benefit from the use of neuromuscular electrical stimulation (NMES), which can improve muscle strength and function, range of motion, exercise capacity, and quality of life. Several modalities exist that deliver this therapy. However, with the ever-increasing demand to improve clinical efficiency and costs, digitalize healthcare, optimize data collection, improve care coordination, and increase patient compliance and engagement, newer devices incorporating technologies that facilitate these demands are emerging. One of these devices, an app-controlled home-based NMES therapy system that allows patients to self-manage their condition and potentially increase adherence to the treatment, incorporates a smartphone-based application which allows a cloud-based portal that feeds real-time patient monitoring to physicians, allowing patients to be supported remotely and given feedback. This device is a step forward in improving both patient care and physician efficiency, as well as decreasing resource utilization, which potentially may reduce healthcare costs.

Cementless Total Knee Arthroplasty in Patients Older Than 75 Years.

Some surgeons have been hesitant to use cementless fixation for total knee arthroplasty (TKA) in elderly patients due to concerns regarding successful bone biological fixation. Therefore, this study evaluated: (1) implant survivorship, (2) functional outcomes, (3) radiographic outcomes, and (4) complications in patients over 75 years of age who underwent cementless total knee arthroplasty. A total of 134 patients (142 TKAs) older than 75 years at a single institution between June 2008 and June 2014 were retrospectively reviewed. Their mean follow-up was 4 years (range: 2-8 years). The cohort consisted of 91 women and 43 men who had a mean age of 80 years (range: 76 to 88 years). The preoperative diagnoses were osteoarthritis (n = 107 patients), rheumatoid arthritis (n = 21 patients), and osteonecrosis (n = 6 patients). Descriptive statistics were used to calculate the means and ranges and a Kaplan-Meier analysis was performed to determine the aseptic and all cause implant survivorship. Radiographic evaluation was performed using the new Knee Society Radiographic Evaluation and Scoring System. Functional outcomes at the final follow-up as well as all medical and surgical complications were recorded for each patient. The aseptic implant survivorship was 99.3% (95% CI: 7.9-8.1), and the all cause implant survivorship was 98.6% (95% CI: 7.9-8.1). There was one aseptic revision and one septic revision. At the latest follow-up the mean Knee Society pain score was 93 points (range, 80-100 points), and the mean Knee Society function score was 84 points (range, 70-90 points). On radiographic evaluation, there were no progressive radiolucencies, subsidence, and loosening of prostheses at the latest follow-up. The use of cementless TKA demonstrated excellent survivorship, mid-term clinical and functional outcomes, as well as no progressive radiolucencies or subsidence in patients older than 75 years. In addition, there was a low rate of surgical and medical complications. Therefore, cementless TKA may be a good option for patients older than 75 years.

The Learning Curve Associated with the Administration of Intra-Articular Liposomal Bupivacaine for Total Knee Arthroplasty: A Pilot Study.

INTRODUCTION: Liposomal bupivacaine is a long-acting, local, injectable anesthetic that is used to potentially mitigate post-operative pain after total knee arthroplasty (TKA). In addition, it may reduce opioid use in the post-operative period and shorten lengths-of-stay (LOS). There have been mixed results in the literature with regards to its efficacy, which raises questions regarding the injection technique used. Therefore, we evaluated the learning curve associated with injection techniques prior to, and after, formal teaching. Specifically, we compared differences in: 1) opioid use; 2) LOS; 3) pain intensity; and 4) discharge disposition in patients who did not receive liposomal bupivacaine (no infiltration cohort), received liposomal bupivacaine with less optimal technique (subpar infiltration), and received liposomal bupivacaine with appropriate technique (optimal infiltration) during their primary TKA. MATERIALS AND METHODS: A 1:1:1 ratio of 54 consecutive cases of patients who had no liposomal bupivacaine infiltration, those who had subpar infiltration, and those who had optimal infiltration were included. To evaluate opioid use, the dosages were obtained and converted to their respective morphine milliequivalents (mEq). The total mEq usage was obtained for the day of surgery through post-operative day (POD) 3. LOS was recorded in days. Pain scores were calculated using the visual analogue scale (VAS), obtained from the first post-operative physical therapy note. Discharge status was recorded as discharged to home or rehabilitation. We used an ANOVA test for continuous and X2-square test for categorical variables. RESULTS: When compared to patients who had no infiltration, patients who had subpar infiltration had significantly lower opioid use on day 0, while patients who had optimal infiltration had lower opioid use on post-operative day (POD) 0 and 3. When comparing techniques, opioid use was lower on day 3 for patients who had optimal, as compared to subpar technique. However, LOS and VAS were not significantly different among the three groups. The rehab discharge rate was lower for patients who had optimal as compared to subpar technique. CONCLUSION: There is a learning curve associated with liposomal bupivacaine use, and incorporating an appropriate technique can markedly affect post-operative outcomes. This should be taken into account when evaluating the potential benefits of this peri-articular injection. It appears that liposomal bupivacaine may decrease opioid use and pain scores when optimal infiltration techniques are used.

Use of a Locked Fibular Plate for Fixation of a Vertical Shear Medial Malleolus Fracture: A Case Report.

Vertical shear fractures of the medial malleolus are less common than transverse fractures. These fractures are often treated with lag screws, posteromedial buttress plating, antiglide plates, and neutralization plates with screws. We report on a 37-year-old male who had fractured his ankle after tripping and falling into a ditch. Initially, the patient was treated with closed reduction and a splint for a trimalleolar fracture with a laterally subluxed talus. However, on review of his preoperative radiographs and computed tomography studies, we confirmed a medial malleolus fracture with a vertical shear pattern and communition. Recently, a contoured fibular locking plate has been developed. We considered this plate to be effective for containing the bone in part because of its broader plate design. We present a case in which a fibular locking plate was used successfully as a neutralization plate as an alternative fixation method for a vertical shear medial malleolar fracture.