The temporal effects of variable tourniquet use on pain after total knee arthroplasty.

BACKGROUND: Tourniquet use in total knee arthroplasty (TKA) remains controversial. While widely studied, any temporal effects on pain and opioid utilization have not been investigated. We hypothesized that postoperative opioid utilization increases with increasing tourniquet times in TKA. METHODS: We retrospectively reviewed 1110 TKAs by three arthroplasty surgeons from October 2016 through September 2019. Exclusion criteria included ambulatory surgery, undocumented tourniquet times, simultaneous bilateral TKA, and diagnoses other than osteoarthritis, inflammatory arthritis, or osteonecrosis. Postoperative opioid medications were converted to daily morphine milligram equivalents (MME/day). Secondary outcomes included range of motion (ROM) at 1-month, 3-month, and 1-year visits as well as patient reported outcomes measures (PROMs) at 3 and 12 months. RESULTS: Nine-hundred and eleven patients were included and stratified based on tourniquet use. Three-hundred and four patients were assigned to a "No Use" group (≤10'); 138 patients to "Low Use" (11-60'); 177 patients to "Medium Use" (61-90'); and 292 patients to "Prolonged Use" (91-120). Compared to No Use, MME/day was significantly increased with Medium Use (+7.676 MME/day, p = 0.001) and Prolonged Use (+12.44 MME/day, p =< 0.001). No significant differences were found between No Use and Low Use groups. Estimated blood loss (EBL) in Low Use and No Use groups was significantly increased compared to other groups (+120 mL, p < 0.001, +109 mL, p < 0.001 respectively). Post-operative ROM and complication rates were similar between groups at 1 year post-TKA. CONCLUSIONS: A threshold of 60 min of tourniquet time is associated with increased MME/day postoperatively compared to No Tourniquet. Functional and patient-reported outcomes are comparable between groups at 1 year follow-up.

Hyaluronan Injections Show No Histologic Evidence of Adverse Tissue Effects.

BACKGROUND: The safety of hyaluronan intra-articular injections is mostly based on animal studies and clinical evidence rather than histologic studies from human administration. OBJECTIVE: This study analyzed the histologic effects of viscosupplementation with sodium hyaluronate on the synovium and articular cartilage of human knee specimen status post total knee arthroplasty within 3 years of viscosupplementation. METHODS: Twenty-four specimens from total knee arthroplasties from April 2012 to August 2016 at NYU Winthrop Hospital were selected for microscopic analysis. All cases had a diagnosis of end-stage osteoarthritis at the time of surgery. Thirteen of the cases had 3 viscosupplementation injections of the knee with Euflexxa, a hyaluronate-based viscosupplementation agent, within 3 years preceding a total knee replacement. The remaining 11 did not receive viscosupplementation and were incorporated as controls. Upon histologic review, synovium was categorized by degree of hyperplasia and inflammation and the presence or absence of foreign material and giant cell reactions. Residual articular cartilage was categorized by staining intensity, and the presence or absence of crystals, foreign material, and giant cell reactions. RESULTS: No significant difference was found between these groups for degree of synovial hyperplasia (P = .33) or for cartilage staining density (P = .42). None of the samples displayed evidence of foreign material, crystals, or giant cell reactions. CONCLUSION: In this cohort of patients, we demonstrated that Euflexxa was administered without any discernible microscopic adverse tissue effects.

A Meta-Analysis of Outcomes in Total Hip Arthroplasty Recipients Following Pelvic Irradiation.

BACKGROUND: Alongside advances in total hip arthroplasty (THA), innovations in the treatment of cancer have led to an increasing number of patients living with this devastating disease. Radiation therapy has well-documented clinical effects on bone health, leading to pelvic insufficiency fractures and osteonecrosis of the femoral head. The purpose of this meta-analysis is to report on THA outcomes in this patient population in an effort to determine if a need to change management exists during surgical planning. METHODS: Following the Preferred Reporting Items for Systematic Review and Meta-Analysis protocols, a systematic review of published literature through August 5th, 2018 was conducted. This resulted in 8 studies in which the primary outcome measures evaluated were rates of aseptic loosening and revision THA. RESULTS: Among 232 hips at a weighted mean follow-up time of 52 months, the aseptic loosening rate was 10% and revision THA rate was 12%. Sub-analysis of 116 THAs with cementless cups demonstrated an aseptic loosening and revision THA rate of 8% and 10%, respectively. CONCLUSION: The findings of the present study indicate that THA recipients who have received radiation therapy to the pelvis before arthroplasty surgery have higher rates of aseptic loosening and revision THA when compared with previously published rates in healthy THA recipients. Additionally, it is possible that female THA recipients who have received pelvic irradiation may be at a higher risk for aseptic loosening and revision THA. Surgeons should counsel patients with a history of pelvic irradiation about their potentially higher risk for these complications. LEVEL OF EVIDENCE: Level I, meta-analysis, and systematic review.

Development of a Saw Bones Model for training pedicle screw placement in scoliosis.

OBJECTIVE: The purpose of this study was to determine if a Sawbones Scoliosis Model could be used as a simulator to train residents in placing pedicle screws-a complex procedure with a steep learning curve. Surgical simulation, a common tool teaching residents complex procedures in a safe environment, was staged using a Sawbones Scoliosis Model. Ten junior and ten senior residents out of 25 total possible residents (80%) were instructed how to place pedicle screws using the free-hand technique. They were then asked to place them unilaterally from T4 to L4 and were assessed on completion time, accuracy placement accuracy, and overall competency using an objective rating scale. RESULTS: Senior residents had an average time to completion of 38.9 ± 4.7 min vs. junior's 50.1 ± 11.7 min, and a pedicle screw accuracy of 43.6 ± 6.4% vs. junior's 44.4 ± 17.4%. Overall competency scores were similar for both groups; however, senior residents scored higher in the time and motion subdomain. Senior residents had a faster completion time and were more efficient, suggesting greater experience in spine surgery. The low rate of screw accuracy in both groups validates that simulation is a safe way for trainees to learn complex tasks.

Novel Spiked-Washer Repair Is Biomechanically Superior to Suture and Bone Tunnels for Arcuate Fracture Repair.

OBJECTIVES: Injuries to the posterolateral corner of the knee can lead to chronic degenerative changes, external rotation instability, and varus instability if not repaired adequately. A proximal fibula avulsion fracture, referred to as an arcuate fracture, has been described in the literature, but a definitive repair technique has yet to be described. The objective of this study was to present a novel arcuate fracture repair technique, using a spiked-washer with an intramedullary screw, and to compare its biomechanical integrity to a previously described suture and bone tunnel method. METHODS: Ten fresh-frozen cadaveric knees underwent a proximal fibula osteotomy to simulate a proximal fibula avulsion fracture. The lateral knee capsule and posterior cruciate ligament were also sectioned to create maximal varus instability. Five fibulas were repaired using a novel spiked-washer technique and the other 5 were repaired using the suture and bone tunnel method. The repaired knees were subjected to a monotonic varus load using a mechanical testing system instrument until failure of the repair or associated posterolateral corner structures. RESULTS: Compared with the suture repair group, the spiked-washer repair group demonstrated a 100% increase in stiffness, 100% increase in yield, 110% increase in failure force, and 108% increase in energy to failure. CONCLUSIONS: The spiked-washer technique offers superior quasi-static biomechanical performance compared with suture repair with bone tunnels for arcuate fractures of the proximal fibula. Further clinical investigation of this technique is warranted and the results of this testing may lead to improved outcomes and patient satisfaction for proximal fibula avulsion fractures.

Lateral ankle stabilization after distal fibular resection using a novel approach: a surgical technique.

BACKGROUND: After tumor resection involving the distal fibula, the method for recreating stability of the lateral ankle remains controversial. Many reconstructive options exist, including allograft reconstruction and arthrodesis; however, each of these approaches has significant potential disadvantages. DESCRIPTION OF TECHNIQUE: The distal fibula is resected as necessary to obtain negative margins for local control of the neoplasm. Reconstruction of the lateral ankle ligamentous complex is performed using the peroneus brevis tendon to reestablish lateral and anterior stability of the tibiotalar joint. The peroneus brevis tendon is transected proximally at it myotendinous junction and then sutured to the calcaneofibular and anterior talofibular ligaments in sequence and then tenodesed to the lateral distal tibia with suture anchors and a staple. METHODS: We present three patients who underwent distal fibulectomy for tumors originating in the distal fibula. All patients who have undergone the reconstruction being described are included within this cohort study. The patients were assessed clinically and radiographically at a range of 14 months to 9.5 years (average, 4.8 years) for functional recovery, return of range of motion, stability of the ankle, and imaging evidence of arthrosis and instability. RESULTS: There were no episodes of instability or early progression to arthrosis. In addition, all patients obtained excellent ankle stability and range of motion on examination, but two had complications. One sustained a traumatic fracture to the base of the fifth metatarsal that healed with nonsurgical treatment and another who underwent further fibular shortening and bursectomy at the tip of the residual fibula with complete relief of his symptoms. CONCLUSIONS: Reconstruction of the lateral ankle after distal fibular resection is possible using the peroneus brevis tenodesed to the distal tibia and sutured to the remnants of the calcaneofibular and anterior talofibular ligaments as described in this surgical technique. In this small group, we found that patients were able to return to normal daily activities without instability or progression to tibiotalar arthrosis at short term; however, longer followup and larger series of patients are called for to confirm these findings.