Prevalence of total joint arthroplasty in the adult spine deformity population.

PURPOSE: The spine, hip, and knee are anatomically and biomechanically connected. Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are commonly employed to treat degenerative changes in the hip and knee, while fusion is used for spine degeneration. Spine deformity correction results in changes in sagittal alignment and pelvic parameters, and patients with stiff spines have higher rates of THA dislocation and revision due to instability. The goal of this study was to determine the prevalence of total joint arthroplasty (TJA) in adult spinal deformity (ASD) patients at our institution. METHODS: Following Institutional Review Board approval, we retrospectively reviewed a list of cases performed by the senior author from 4/2017 to 5/2021. Patients > 18 years old undergoing preoperative evaluation for symptomatic lumbar degeneration or ASD were included. Patients < 18 years old, those diagnosed with adolescent idiopathic scoliosis, and non-fusion cases were excluded. Perioperative full-length standing EOS images were examined for the presence or absence of THA, TKA, or both. Demographic data was collected from patient electronic medical records, and statistical analyses were completed. RESULTS: 572 consecutive cases were reviewed, and 322 were excluded. 250 cases (97M:153F) were included in the final analysis, with a mean age of 61.8 ± 11.2 years. A total of 74 patients had a TJA (29.4%). THA was present in 41 patients (16.4%), and TKA was present in 49 patients (19.6%). Males had a higher prevalence of TJA, THA, and TKA (29.9%, 16.5%, and 21.6%) than females (29.4%, 16.3%, and 18.3%). CONCLUSIONS: This study revealed a high prevalence TJA rate of 29.4% in ASD at our institution. This rate surpasses the prevalence rate reported among the general population in previous studies. High prevalence of patients with ASD and TJA may merit special surgical consideration.

Hip and Knee Osteoarthritis, Not Nonsteroidal Anti-Inflammatory Drugs, are Linked to Cardiac Disease.

BACKGROUND: In 2005, the Food and Drug Administration placed a black-box warning (the most stringent warning for drugs) on all nonaspirin nonsteroidal anti-inflammatory drugs (NSAIDs) stating that these agents may cause heart attacks and/or strokes. No level I evidence demonstrates that nonselective NSAIDs increase cardiovascular risk. An alternative hypothesis is that hip and knee osteoarthritis (OA) indirectly causes cardiovascular disease (CVD) through decreased activity and NSAIDs are correlated with CVD as an arthritis treatment. METHODS: Systematic reviews were conducted to find observational studies evaluating the association of hip and/or knee OA, CVD, activity, walking, and step counts. The systematic review found studies correlating hip and/or knee OA and CVD morbidity incidence (n = 2); CVD morbidity prevalence (n = 6); odds ratios, relative risks, or hazard ratios of CVD morbidity (n = 11); relative risk, standardized mortality ratios, or hazard ratios of CVD mortality (n = 14); and all-cause mortality hazard ratios associated with NSAID use (n = 3). RESULTS: Hip OA (5 studies), knee OA (9 studies), and hip and knee OA (6 studies) are linked to an increased risk of CVD morbidity and mortality. Cardiac risk increases with validated disability scores, use of walking aids, walking difficulties, longer follow-up times, younger ages of OA onset, numbers of joints involved, and OA severities. No study linked NSAID use to cardiac disease. CONCLUSIONS: All studies with more than 10-year follow-up linked cardiac disease with hip and knee OA. No study linked nonselective NSAID use to CVD. The Food and Drug Administration should reconsider the black-box warnings on naproxen, ibuprofen, and celecoxib.

Editorial Commentary: Consider the Sacroiliac Joint: Imaging a Source of Pain Can Feel Compelling. Orthopaedists Would Do Well to Remain Skeptical.

With regard to the association of sacroiliac (SI) pain and hip arthroscopy outcomes, it is vital to understand that imaging the SI joint may be unreliable. A recent systematic review on diagnostic accuracy for SI joint pain concluded that more reliable criteria are strongly positive responses to diagnostic injection and a physical examination in which 3 or more provocative maneuvers are positive. SI joint degenerative changes can be found in a majority of asymptotic patients and might be considered normal finding until proven otherwise. When it comes to the spine and pelvis, radiologic changes should be interpreted by caution by both hip surgeons and spine surgeons.

How often is the office visit needed? Predicting total knee arthroplasty revision risk using pain/function scores.

BACKGROUND: Most patients have favorable outcomes after primary total knee arthroplasty (TKA). Well-validated methods to predict the risk of poor outcomes have not been developed or implemented. Several patients have annual clinic visits despite well-funcitoning TKA, as a routine practice, to detect early failure requiring revision surgery. It is not known whether assessment of pain and function can be used as a predictive tool for early failure and revision to guide practice. Our objective was to determine whether pain and function can predict revision after TKA. METHODS: We retrospectively studied data from a large prospectively gathered TKA registry to examine changes in outcome scores for primary TKAs undergoing revision compared to those not requiring revision to determine the factors that are predictive for revision. RESULTS: Of the 1,012 patients, 721 had had a single-sided primary TKA and had American Knee Society (AKS) Scores for three or more visits. 46 patients underwent revision, 23 acutely (fracture, traumatic component failure or acute infection) and 23 for latent causes (late implant loosening, progressive osteolysis, or pain and indolent infection). Mean age was 70 years for the non-revision patients, and 64 years for those revised. Both AKS Clinical and AKS Function Scores for non-revised patients were higher than in revision patients, higher in acute revision compared to latent revision patients. Significant predictors of revision surgery were preoperative, 3- and 15-month postoperative AKS Clinical Scores and 3-month AKS Function Scores. At 15-month post-TKA, a patient with a low calculated probability of revision, 32 % or less, was unlikely to require revision surgery with a negative predictive value of 99 %. CONCLUSION: Time dependent interval evaluation post-TKA with the AKS outcome scores may provide the ability to assign risk of revision to patients at the 15-month follow-up visit. If these findings can be replicated using a patient-reported measure, a virtual follow-up with patient-reported outcomes and X-ray review may be an alternative to clinic visit for patients doing well.

Symptomatic sacroiliac joint disease and radiographic evidence of femoroacetabular impingement.

Symptomatic sacroiliac (SI) joint disease is poorly understood. The literature provides no clear aetiology for SI joint pathology, making evaluation and diagnosis challenging. We hypothesised that patients with documented sacroiliac pain might provide insight into the aetiology of these symptoms. Specifically, we questioned whether SI joint symptoms might be associated with abnormal hip radiographs. We reviewed the pelvic and hip radiographs of a prospectively collected cohort of 30 consecutive patients with SI joint pathology. This database included 33 hips from 30 patients. Radiographic analysis included measurements of the lateral centre edge angle, Tönnis angle, and the triangular index, of the ipsilateral hip. Evidence for retrotorsion of the hemipelvis was recorded. Hips were graded on the Tönnis grading system for hip arthrosis. In this cohort 14/33 (42%) of hips had evidence of significant osteoarthrosis indicated by Tönnis grade 2 or greater and 15/33 (45%) displayed subchondral cyst formation around the hip or head neck junction. In assessing acetabular anatomy, 21% (7/33) had retroversion, 12% (4/33) had a lateral centre edge angle >40° with 3% (1/33) >45°. Tönnis angle was <0° in 27% (9/33). Coxa profunda and acetabuli protrusio were present in 47% (17/33) and 3% (1/33), respectively. When femoral head morphology was assessed, 33% (11/33) showed evidence of cam impingement. Overall, 76% (25/33) had at least one abnormality on their hip radiograph. A significant number of patients meeting strict diagnostic criteria for SI joint pain had radiographic evidence of femoroacetabular impingement (FAI) and hip arthrosis. The clinician should maintain FAI in the differential diagnosis when investigating patients with buttock pain.

Reliability of various observers in determining common radiographic parameters of adult hip structural anatomy.

BACKGROUND: Radiographic evaluation of the hip is extremely important in the diagnosis and treatment decisionmaking process for pre-arthritic hip disease. Many different radiographic measurements have been described as indicators of underlying structural hip deformity. The purpose of this study was to determine the interobserver and intraobserver reliability of various musculoskeletal physicians in performing selected measurements of adult structural hip anatomy. METHODS: A blinded review of 45 sets of radiographs from patients with developmental dysplasia, femoro-acetabular impingement, and normal anatomy was performed. Data points included the lateral center-edge angle (LCEA), vertical-center-anterior angle (VCA), head-neck offset ratio (UNO), alpha angle, Tönnis angle, Tönnis osteoarthritis grade and a radiographic diagnosis. One orthopaedic fellow, two orthopaedic residents, and two attending musculoskeletal physiatrists analyzed radiographs on two separate occasions. One sports medicine orthopaedic attending physician completed a single analysis of the image sets. Intraobserver and interobserver reliability was established using intra-class correlation coefficients (ICC) for continuous variables. Agreement regarding categorical variables was performed using the kappa coefficient RESULTS: Excellent intraobserver reliability was found for the following: LCEA (ICC = 0.88), VCA (0.88), Tönnis angle (0.83), HNO on the frog lateral (0.78), alpha angle on the frog lateral (0.76), HNO on the cross-table lateral (0.75), and angle alpha on the cross-table lateral (0.76). Intraobserver reliability for osteoarthritis grade was poor (weighted kappa = 0.57). For all data points, interobserver reliability was considerably worse, with 95% confidence intervals spanning below 0.55. CONCLUSIONS: While the described measurements of adult structural hip anatomy provide excellent reliability for a given reader, these measurements are less reliable across readers. Taken in isolation, these measurements, as performed by observers with varied clinical experience and clinical backgrounds, are limited in determining a consistent radiographic diagnosis.

The role of the oblique popliteal ligament and other structures in preventing knee hyperextension.

BACKGROUND: Ligament restraints to terminal knee extension are poorly understood. HYPOTHESES: (1) As with other motions of the knee, genu recurvatum is limited primarily by a named, identifiable structure. (2) As the largest static structure of the posterior knee, the oblique popliteal ligament is uniquely suited to act as a checkrein to knee hyperextension. STUDY DESIGN: Descriptive laboratory study. METHODS: Twenty fresh-frozen human knees were divided into 3 groups for a ligament sectioning study. Extension moments of 14 and 27 N x m were applied before and after sectioning of each ligament, and motion changes were recorded. In group 1, the oblique popliteal ligament was sectioned first, followed by the fabellofibular ligament, ligament of Wrisberg, anterior cruciate ligament, posterolateral structures, and posterior cruciate ligament. In group 2, the order was altered to section the anterior cruciate ligament first; no other changes were made. Similarly, the cutting order for group 3 was altered to section the posterior cruciate ligament first. The sagittal tibial slope of each specimen was documented off a lateral radiograph. RESULTS: The greatest increase in knee hyperextension was observed after sectioning the oblique popliteal ligament. This was independent of cutting order, consistent across groups, and statistically significant. In all groups, the increase in knee hyperextension after sectioning the oblique popliteal ligament approached or exceeded the increases seen after sectioning the anterior and posterior cruciate ligaments combined. Overall, less knee hyperextension was seen in knees with increased posterior tibial slope. CONCLUSION: The oblique popliteal ligament was found to be the primary ligamentous restraint to knee hyperextension. CLINICAL RELEVANCE: Further studies are needed to determine if surgical repair or reconstruction of the oblique popliteal ligament can restore normal motion limits in patients with symptomatic genu recurvatum. Patients with decreased posterior tibial slope would have increased recurvatum with posterior structure injury, which increases the likelihood of increased symptoms in this population.

Prophylactic antibiotics do not affect cultures in the treatment of an infected TKA: a prospective trial.

UNLABELLED: Prophylactic antibiotics are frequently withheld until cultures are obtained in revision total knee arthroplasty (TKA). We undertook a prospective study to determine whether prophylactic preoperative intravenous antibiotics would affect the results of cultures obtained intraoperatively. We enrolled 25 patients with 26 infected TKAs, a known preoperative infecting organism, and no recent antibiotic therapy. Reaspiration of the infected TKA was performed after anesthesia and sterile preparation. Intravenous antibiotic prophylaxis was then administered and the tourniquet inflated. Intraoperative culture swabs and tissue were obtained at arthrotomy. The timing of events was recorded. Pre- and postantibiotic culture data were analyzed to determine the effect of intravenous preoperative prophylactic antibiotics on cultures obtained intraoperatively. Infections were acute postoperative (four), chronic (19), and acute hematogenous (three). The most common infecting organism was cloxacillin-sensitive Staphylococcus aureus (nine knees [35%]). Preoperative prophylactic antibiotics did not affect the results of intraoperative cultures and we therefore believe should not be withheld before surgery for an infected TKA when an organism has been identified on aspiration preoperatively, and there has been no recent (4 weeks) antimicrobial therapy. LEVEL OF EVIDENCE: Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

The value of intraoperative Gram stain in revision total knee arthroplasty.

BACKGROUND: The accurate preoperative diagnosis of infection is an essential component of decision-making prior to revision total knee arthroplasty. When preoperative modalities used to detect infection reveal equivocal findings, the surgeon may rely on intraoperative testing. While intraoperative Gram stains are routinely performed during revision total knee arthroplasty, their value remains unclear. METHODS: We retrospectively reviewed the records on 945 revision total knee arthroplasties performed at three university institutions to which patients were referred for total joint arthroplasty; the results of an intraoperative Gram stain were available for review in 921 cases (97.5%). Of these knees, 247 were classified as infected on the basis of (1) the presence of the same organism in two cultures; (2) growth, on solid media, of an organism as well as other objective evidence of infection; (3) histologic evidence of acute inflammation; (4) gross purulence; and/or (5) an actively draining sinus. We reviewed the results of preoperative laboratory studies, which included measurements of the erythrocyte sedimentation rate, C-reactive protein values, and white blood-cell count in 90%, 76%, and 98% of cases, respectively. Preoperative aspiration to obtain a specimen for culture and a cell count was performed routinely at one center and selectively at the other two centers, and the results were available for review in 439 (48%) of the 921 cases. RESULTS: Intraoperative Gram staining was found to have a sensitivity of 27% and a specificity of 99.9%. The positive and negative predictive values were 98.5% and 79%, respectively. The test accuracy was 80%. Patients with a true-positive Gram stain had a significantly higher preoperative white blood-cell count, C-reactive protein level, and nucleated cell count in the aspirate when compared with patients with a false-negative Gram stain (p < 0.001). In no case did the results of the intraoperative Gram stain alter treatment. CONCLUSIONS: The intraoperative Gram stain was found to have poor sensitivity and a poor negative predictive value, and its results did not alter the treatment of any patient undergoing revision total knee arthroplasty because of a suspected infection. These data do not support the routine use of intraoperative Gram staining in revision total knee arthroplasty; instead, they suggest a much more limited role for this test.

Factors influencing early rehabilitation after THA: a systematic review.

UNLABELLED: A wide variation exists in rehabilitation after total hip arthroplasty (THA) in part due to a paucity of evidence-based literature. We asked whether a minimally invasive surgical approach, a multimodal approach to pain control with revised anesthesia protocols, hip restrictions, or preoperative physiotherapy achieved a faster rehabilitation and improved immediate short-term outcome. We conducted a systematic review of 16 level I and II studies after a strategy-based search of English literature on OVID Medline, PubMed, CINAHL, Cochrane, and EMBASE databases. We defined the endpoint of assessment as independent ambulation and ability to perform activities of daily living. Literature supports the use of a multimodal pain control to improve patient compliance in accelerated rehabilitation. Multimodal pain control with revised anesthesia protocols and accelerated rehabilitation speeds recovery after minimally invasive THA compared to the standard approach THA, but a smaller incision length or minimally invasive approach does not demonstrably improve the short-term outcome. Available studies justify no hip restrictions following an anterolateral approach but none have examined the question for a posterior approach. Preoperative physiotherapy may facilitate faster postoperative functional recovery but multicenter and well-designed prospective randomized studies with outcome measures are necessary to confirm its efficacy. LEVEL OF EVIDENCE: Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The anatomy of the posterior aspect of the knee. An anatomic study.

BACKGROUND: The orthopaedic literature contains relatively little quantitative information regarding the anatomy of the posterior aspect of the knee. The purpose of the present study was to provide a detailed description of, and to propose a standard nomenclature for, the anatomy of the posterior aspect of the knee. METHODS: Detailed dissection of twenty nonpaired, fresh-frozen knees was performed. Posterior knee structures were measured according to length, width, and/or distance to reproducible osseous landmarks. RESULTS: The semimembranosus tendon had eight attachments distal to the main common tendon. The main components were a lateral expansion to the oblique popliteal ligament; a direct arm, which attached to the tibia; and an anterior arm. The oblique popliteal ligament, the largest posterior knee structure, formed a broad fascial sheath over the posterior aspect of the knee and measured 48.0 mm in length and 9.5 mm wide at its medial origin and 16.4 mm wide at its lateral attachment. It had two lateral attachments, one to the meniscofemoral portion of the posterolateral joint capsule and one to the tibia, along the lateral border of the posterior cruciate ligament facet. The semimembranosus also had a distal tibial expansion, which formed a posterior fascial layer over the popliteus muscle. A thickening of the posterior joint capsule, the proximal popliteus capsular expansion, which in this study averaged 40.5 mm in length, connected the posteromedial knee capsule at its attachment at the intercondylar notch to the medial border of the popliteus musculotendinous junction. The plantaris muscle, popliteofibular ligament, fabellofibular ligament, and semimembranosus bursa were present in all specimens. CONCLUSIONS: The anatomy of the posterior aspect of the knee is quite complex. This study provides information that can lead to further biomechanical, radiographic imaging, and clinical studies of the importance of these posterior knee structures.