Technology-Assisted Hip and Knee Arthroplasty in Orthopaedic Residency Training: A National Survey.

INTRODUCTION: The adoption of technology-assisted total joint arthroplasty (TA-TJA) is increasing; however, the extent to which TA-TJA is used among orthopaedic trainees is unknown. The purpose of this study was to assess the current use of TA total knee arthroplasty (TKA) and total hip arthroplasty (THA) by orthopaedic residents and to evaluate resident perceptions toward TA-TJA in their surgical training. METHODS: In this cross-sectional study, an anonymous electronic survey was sent to all Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency program coordinators to distribute to their PGY-2 to PGY-5 residents. The survey consisted of 24 questions, including resident demographics, utilization of TA-TJA in their training, and perceptions regarding TA-TJA. RESULTS: A total of 103 orthopaedic residents completed the survey, of whom 68.0% reported using TA-TJA at their institution. Of the residents using TA-TJA, 28.6% used TA for total TKA only, 71.4% used TA for both TKA and THA, and none used TA solely for THA. One-third of residents (33.3%) use TA for more than half of all TKAs conducted, whereas 57.0% use TA for <10% of all THAs conducted. Approximately half of all residents (49.5%) thought that training in TA-TJA should be required during residency, with no significant differences between junior and senior level residents ( P = 0.24). Most (82.0%) thought that trainees should be required to learn conventional TJA before learning TA-TJA. 63.0% thought that technology had a positive effect on their primary TJA training experience; however, 26.0% reported concern that their training conducting conventional TJA may be inadequate. DISCUSSION: This study demonstrates that most orthopaedic residents currently conduct TA-TJA and highlights notable differences in TJA training experiences. These results provide a platform for future work aimed at further optimizing TJA training in residency, particularly as technology continues to rapidly evolve and utilization of TA-TJA is projected to grow exponentially. LEVEL OF EVIDENCE: N/A, survey-based study.

The Impact of Hospital Size and Teaching Status on Outcomes Following Total Ankle Arthroplasty.

The popularity and utilization of total ankle arthroplasty (TAA) as treatment for ankle arthritis has increased exponentially from 1998 to 2012. Overall the outcomes have improved for TAA with the introduction of new-generation implants and this has increased the focus on optimizing other variables affecting outcomes for TAA. The purpose of this study was to examine the effects of hospital characteristics and teaching status on outcomes for TAA. The Nationwide Inpatient Sample database was queried from 2002 to 2012 using the ICD-9 procedure code for TAA. The primary outcomes evaluated included: in-hospital mortality, length of stay, total hospital charges, discharge disposition, perioperative complications, and patient demographics. Analyses were carried out based on hospital size: small, medium, and large; and teaching status: rural nonteaching, urban nonteaching, and urban teaching. A total weighted national estimate of 16,621 discharges for patients undergoing TAA was reported over the 10-year period. There were significant differences in length of stay and total charges between all hospitals when comparing location and teaching status; however, no significant differences were noted for in-hospital mortality. Rural, nonteaching hospitals had higher odds of perioperative complications. There were also significant differences in length of stay and total charges when comparing hospital sizes. Overall, there is no increased risk of mortality after TAA regardless of hospital size or setting. However, rural hospitals had increased rates of perioperative complications compared to urban hospitals. Our analyses demonstrated important factors affecting cost and resource utilization for TAA, clearly additional work is needed to optimize this relationship, especially in the upcoming bundled payment models.

Articular Cartilage of the Syndesmosis: Avoiding Iatrogenic Cartilage Injury During Syndesmotic Fixation.

BACKGROUND: The optimal surgical management of syndesmosis injuries consists of internal fixation between the distal fibula and tibia. Much of the available data on this joint details the anatomy of the syndesmotic ligaments. Little is published evaluating the distribution of articular cartilage of the syndesmosis, which is of importance to minimize the risk of iatrogenic damage during surgical treatment. The purpose of this study is to describe the articular cartilage of the syndesmosis. METHODS: Twenty cadaveric ankles were dissected to identify the cartilage of the syndesmosis. Digital images of the articular cartilage were taken and measured using calibrated digital imaging software. RESULTS: On the tibial side, distinct articular cartilage extending above the plafond was identified in 19/20 (95%) specimens. The tibial cartilage extended a mean of 6 ± 3 (range, 2-13) mm above the plafond. On the fibular side, 6/20 (30%) specimens demonstrated cartilage proximal to the talar facet, which extended a mean of 24 ± 4 (range, 20-31) mm above the tip of the fibula. The superior extent of the syndesmotic recess was a mean of 10 ± 3 (range, 5-17) mm in height. In all specimens, the syndesmosis cartilage did not extend more than 13 mm proximal to the tibial plafond and the syndesmotic recess did not extend more than 17 mm proximal to the tibial plafond. CONCLUSION: Syndesmosis fixation placed more than 13 mm proximal to the tibial plafond would have safely avoided the articular cartilage in all specimens and the synovial-lined syndesmotic recess in most. CLINICAL RELEVANCE: This study details the articular anatomy of the distal tibiofibular joint and provides measurements that can guide implant placement during syndesmotic fixation to minimize the risk of iatrogenic cartilage damage.

Comparison of Outcomes After Robotic-Assisted or Conventional Total Hip Arthroplasty at a Minimum 2-Year Follow-up: A Systematic Review.

BACKGROUND: This systematic review aimed to present an updated analysis of the evidence comparing outcomes between robotic-assisted total hip arthroplasty (robotic THA) and conventional manual total hip arthroplasty (manual THA). METHODS: A PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) systematic review was performed using the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, MEDLINE, and Embase. Controlled studies comparing primary robotic THA and manual THA utilizing patient-reported outcome measures (PROMs) at a minimum follow-up of 2 years were included. We also compared radiographic outcomes, dislocation rates, and revision surgical procedures between groups. The ROBINS-I (Risk of Bias in Non-Randomized Studies - of Interventions) and Cochrane Risk of Bias 2.0 tools were used to assess study quality and risk of bias. RESULTS: Of 765 studies identified, 7 articles comparing robotic THA with manual THA met inclusion criteria. A total of 658 patients were assessed, 335 of whom underwent robotic THA. The majority of studies found no significant differences (p > 0.05) in PROMs between the 2 techniques. Two low-quality studies (Level III) found significantly better postoperative PROMs favoring robotic THA at 2 years. When assessing radiographic outcomes, 6 studies showed that robotic THA resulted in more consistent and accurate component placement. No differences in postoperative dislocations, complications, or revision rates were found between groups except in 1 study, which found significantly more dislocations and revisions in the robotic THA cohort. Reported operative times were a mean of 12 to 25 minutes longer when using robotic THA. CONCLUSIONS: The existing literature comparing robotic THA and manual THA is scarce and low-quality, with findings limited by methodological flaws in study design. Although evidence exists to support increased accuracy and reproducibility of THA component placement with robotic THA, this has not been shown to reduce postoperative dislocation and revision rates. Based on the available evidence, functional outcomes are comparable between techniques, and robotic THA appears to be associated with longer operative times. To fully evaluate the utility of robotic THA, additional well-designed, prospective controlled studies with continuous long-term monitoring are required. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pain After Anatomic Total Shoulder Arthroplasty Versus Reverse Total Shoulder Arthroplasty.

As anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) become increasingly common, differences between the 2 procedures are of importance. The purpose of this study was to determine differences in acute pain levels between patients undergoing aTSA and rTSA. Sixty patients undergoing aTSA or rTSA were assessed for participation. The primary outcome was postoperative daily visual analog scale scores, which were initially collected for 4 days postoperatively. Secondary outcomes included opioid consumption, length of stay, and complications. Comparisons between the 2 groups were assessed using a multivariable analysis, which controlled for sex, age, body mass index, and type of anesthetic. A total of 57 patients consented and were analyzed. No significant differences were found in postoperative visual analog scale scores in the first 4 days following surgery or at 1 year postoperatively. Patients undergoing aTSA had a higher mean opioid requirement in the first 4 hours postoperatively (1.0±0.7 vs 0.4±0.6 morphine milligram equivalents, P<.01). Forty percent of patients undergoing shoulder arthroplasty were prescribed narcotics within the 3 months prior to surgery. Patients who were prescribed narcotics prior to surgery were more likely to continue to require narcotics at extended time periods postoperatively. Patients undergoing aTSA required more opioid medication in the immediate postoperative period. However, after 4 hours postoperatively, no significant differences in pain scores or opioid consumption were found. These findings suggest that patients undergoing aTSA or rTSA have similar postoperative pain profiles. Patients who are prescribed narcotics before shoulder arthroplasty are at an increased risk for postoperative opioid demand. [Orthopedics. 2019; 42(2):e247-e252.].

Clinical Characteristics and Long-term Outcomes After Septic Arthritis of the Native Glenohumeral Joint: A 20-Year Retrospective Review.

Septic arthritis of the native glenohumeral joint is rare, and there is little information available regarding the natural progression and long-term joint outcomes of this pathology. The authors performed a retrospective analysis of 97 patients with culture-positive glenohumeral septic arthritis between 1995 and 2015 at their institution with a mean clinical follow-up of 83.1 months. Patient records were reviewed to document demographic and laboratory data, clinical presentation, postoperative complications, recurrences, and subsequent shoulder arthroplasty. Common comorbidities uncovered included 20 immunocompromised patients (20.6%), intravenous drug use among 27 patients (27.8%), diabetes mellitus among 40 patients (41.2%), and 18 patients (18.5%) receiving hemodialysis. Staphylococcus aureus was the most common pathogen identified (61 patients; 62.8%), followed by streptococcal species (17 patients; 17.2%). Hematogenous spread of infection was the most common etiology of shoulder sepsis (40.2%). Seven patients (7.2%) developed shoulder sepsis of undetermined etiology in the absence of established risk factors, and 16 patients (16.4%) developed recurrent glenohumeral septic arthritis at a mean of 40 months following initial eradication of infection. Three patients (3.0%) eventually underwent same-side shoulder arthroplasty at a mean of 18 months following septic arthritis, with none experiencing a periprosthetic joint infection. Glenohumeral septic arthritis is highly unlikely in the absence of medical risk factors. Long-term recurrence after clinically successful treatment is low (16.5%), and few patients undergo elective arthroplasty following shoulder septic arthritis. However, orthopedic surgeons can expect 30% to 40% of patients to require multiple trips to the operating room to successfully treat the initial joint infection, regardless of treatment method. [Orthopedics. 2019; 42(1):e118-e123.].

Osteochondral Allograft Transplantation in the Patellofemoral Joint: A Systematic Review.

BACKGROUND: The initial focus of cartilage restoration algorithms has been on the femur; however, the patellofemoral compartment accounts for 20% to 30% of significant symptomatic chondral pathologies. While patellofemoral compartment treatment involves a completely unique subset of comorbidities, with a comprehensive and thoughtful approach many patients may benefit from osteochondral allograft treatment. PURPOSE: To perform a systematic review of clinical outcomes and failure rates after osteochondral allograft transplantation (OCA) of the patellofemoral joint at a minimum 18-month follow-up. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature regarding the existing evidence for clinical outcomes and failure rates of OCA for patellofemoral joint chondral defects was performed with the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed, and MEDLINE from studies published between 1990 and 2017. Inclusion criteria were as follows: clinical outcomes and failure rates of OCA for the treatment of chondral defects in the patellofemoral joint, English language, minimum follow-up of 18 months, minimum study size of 5 patients, and human studies. The methodological quality of each study was assessed with a modified version of the Coleman methodology score. RESULTS: The systematic search identified 8 studies with a total of 129 patients. The methods of graft procurement and storage time included fresh (121 patients, 93.8%), and cryopreserved (8 patients, 6.2%) grafts. The mean survival rate was 87.9% at 5 years and 77.2% at 10 years. The following outcome scores showed significant improvement from pre- to postoperative status: modified d'Aubigné-Postel, International Knee Documentation Committee, Knee Society Score-Function, and Lysholm Knee Score. CONCLUSION: OCA of the patellofemoral joint results in improved patient-reported outcome measures with high patient satisfaction rates. Five- and 10-year survival rates of 87.9% and 77.2%, respectively, can be expected after this procedure. These findings should be taken with caution, as a high percentage of patellofemoral osteochondral allografts were associated with concomitant procedures; therefore, further research is warranted to determine the effect of isolated osteochondral transplantations.

Long-term outcomes of patients with diabetes mellitus undergoing percutaneous intervention for popliteal and infrapopliteal peripheral arterial disease.

OBJECTIVES: To evaluate the association of diabetes mellitus (DM) with clinical and angiographic characteristics and outcomes of patients with popliteal and infrapopliteal peripheral arterial disease (PAD) undergoing peripheral vascular intervention (PVI). BACKGROUND: Clinical features and outcomes in patients with DM and popliteal or infrapopliteal PAD undergoing PVI are not well described. METHODS: Using the data from the laser in popliteal and infrapopliteal stenosis study, we retrospectively examined the association of diabetes with clinical and angiographic characteristics and risk adjusted short- and intermediate term outcomes (all cause death, major adverse events (MAE) [composite of death, ipsilateral major amputation, or repeat revascularization]) in patients with popliteal and infrapopliteal PAD undergoing PVI for critical limb ischemia treated either with laser-assisted balloon angioplasty or balloon angioplasty alone. RESULTS: Of 714 patients, 418 had DM (58.5%). Patients with DM were younger with higher prevalence of history of coronary artery disease, heart failure, end-stage renal disease, and prior contralateral limb amputation compared to those without DM. At 5 years, mean event free survival for all cause mortality (39.9 vs. 45.5 months; P = 0.001), MAE (29.3 vs. 36.8 months; P < 0.001), ipsilateral major amputation (55.3 vs. 57.4 months; P = 0.001), and repeat revascularization (42.0 vs. 45.8 months; P = 0.03) were significantly lower in DM patients. On multivariate analysis, DM was associated with significantly higher all cause mortality (HR = 1.83, 95% CI 1.33-2.52), MAE (HR = 1.73, 95% CI 1.35-2.23), and ipsilateral major amputation (HR = 5.52, 95% CI 1.82-16.71). CONCLUSIONS: Among patients with popliteal and infrapopliteal PAD undergoing PVI, DM was associated with higher mortality, major amputations and MAE that was independent of baseline comorbidities. Our data suggested the need for future studies evaluating existing and/or novel therapies to improve the poor long-term outcomes in diabetic patients with popliteal and infrapopliteal PAD.

The impact of preoperative opioid use on outcomes after arthroscopic rotator cuff repair.

BACKGROUND: Preoperative opioid use has been correlated to suboptimal outcomes in orthopedic surgery. This study evaluated the effect of preoperative opioid use on outcomes after arthroscopic rotator cuff repair (RCR). METHODS: A retrospective review was performed of 79 patients who underwent arthroscopic RCR; of these, 31 with a history of preoperative opioid use were compared with a control group of 48 patients without a history of preoperative opioid use. Preoperative and postoperative patient-reported outcomes and functional scores were compared. RESULTS: Both cohorts significantly improved on all patient-reported shoulder scores; however, the nonopioid group demonstrated significantly better postoperative patient-reported outcome scores (P = .015) and external rotation measurement (P = .008). Functional outcomes also significantly improved from preoperatively to postoperatively for forward flexion, but no differences were seen between groups. CONCLUSIONS: Patients with a history of preoperative opioid use can still achieve significant improvements in outcomes after arthroscopic RCR, although not to the same extent as opioid-naïve patients. Therefore, orthopedic surgeons must consider a patient's preoperative opioid use and temper expectations with regard to outcomes so that they are able to set realistic postoperative goals for patients undergoing RCR.