Total Knee Arthroplasty Periprosthetic Joint Infection with Concomitant Extensor Mechanism Disruption and Soft-Tissue Defect: The Knee Arthroplasty Terrible Triad.

BACKGROUND: Periprosthetic infection (PJI) with concomitant extensor mechanism disruption (EMD) and soft-tissue defect - hereinafter termed the "Terrible Triad" - is a devastating complication following total knee arthroplasty (TKA). The purpose of this study was to define the surgical and clinical outcomes following management of a cohort of patients who have the Terrible Triad. METHODS: From 2000 to 2022, 127 patients underwent operative management for PJI alone, 25 for PJI with soft-tissue defects (defined as defects requiring flap reconstruction or being a factor contributing to the decision of performing above-knee amputation (AKA) or arthrodesis), 14 for PJI with EMD, and 22 for the Terrible Triad. A composite outcome of infection status, range of motion, extensor lag, and ambulatory status at final follow-up was used to compare the proportion of patients in each group with a favorable overall knee outcome. Differences between groups were determined using one-way analyses of variance with post hoc Tukey's tests and Pearson's Chi-square tests or Fisher's exact tests with post hoc Bonferroni adjustments, where applicable. Odds ratios (OR) were calculated for comparison of the overall knee outcome between groups. A Kaplan-Meier survival analysis for patient mortality was performed. RESULTS: The mean follow-up was 8.4 years and similar between groups (P = 0.064). Patients who had the Terrible Triad had a 45.5% incidence of AKA, or arthrodesis, and an 86.4% incidence of an unfavorable outcome. Compared to patients in the PJI group, patients in the PJI who had a soft-tissue defect (OR=5.8, 95%CI [confidence interval] 2.2 to 15.7), PJI with EMD (OR=3.7, 95%CI 1.0 to 12.9), and Terrible Triad groups (OR=11.6, 95%CI 3.3 to 41.5) showed higher odds of an unfavorable knee outcome. CONCLUSIONS: This study demonstrates that the TKA Terrible Triad is a dreaded diagnosis with poor outcomes. Clinicians and patients might consider early treatment with amputation or arthrodesis.

Traumaplasty: When and How to Perform Acute Arthroplasty for Fractures Around the Hip in the Elderly Patient.

Acute fractures around the hip are prevalent injuries associated with potentially devastating outcomes. The growing utilization of arthroplasty for femoral neck fractures in the elderly is likely a result of improvements in reoperation rates and postoperative function. Compared to hemiarthroplasty, total hip arthroplasty is associated with a slight functional benefit that is unlikely noticeable for many patients, as well as minimal differences in complications and patient reported outcome measures. However, the evidence supporting cement use in femoral stem fixation is robust. Multiple high power randomized controlled trial-based studies indicate cement fixation brings more predictable outcomes and fewer reoperations. In the setting of acute acetabular fracture, total hip arthroplasty is a favorable approach for elderly patients and fracture patterns associated with increased risk of revision after open reduction and internal fixation. Variations in patient characteristics and fracture patterns demand careful consideration whenever selecting the optimal treatment. In fracture patient populations, comanagement is an important consideration when seeking to reduce complications and promote cost-effective quality care.

Complications and early recovery following hip hemiarthroplasty through the direct anterior approach: a systematic review and meta-analysis.

PURPOSE: Minimizing complications is an important focus in hip hemiarthroplasty (HHA) for femoral neck fracture (FNF) patients given the associated high morbidity and mortality rates. This systematic review and meta-analysis aimed to compare the clinical and functional outcomes associated with the direct anterior approach (DAA) compared to other surgical approaches used for HHA. METHODS: Studies evaluating HHA-treated FNFs using the DAA were compared through meta-analysis to all other surgical approaches combined and as distinct subgroups. Outcomes included overall complication rate, mortality rate, dislocation rate, reoperation rate, periprosthetic fracture rate, infection rate, length of stay (LOS), mobility, perioperative blood loss, operative time, and postoperative pain. RESULTS: Nineteen studies met the inclusion criteria, totaling 2,018 HHAs. DAA significantly reduced the overall complication rate (odds ratio (OR) = 0.73, 95% confidence interval (CI) 0.57 to 0.94, p = 0.01), dislocation rate (OR = 0.34, 95% CI 0.15 to 0.77, p = 0.01), and LOS (mean difference (MD) = -1.31 days, 95% CI - 2.12 to - 0.50, p = 0.002). Findings from studies that were not appropriate for meta-analysis were qualitatively summarized and suggested improved mobility and reduced postoperative pain with the DAA. Significant differences were not detected in any of the remaining outcomes. CONCLUSION: The DAA HHA appears to be safer, reduces hospital stay, and may improve early functional recovery. This article supports the DAA HHA as a safe option for the management of displaced intracapsular FNFs.

Improving Resource Utilization for Arthroplasty Care by Leveraging Machine Learning and Optimization: A Systematic Review.

Background: There is a growing demand for total joint arthroplasty (TJA) surgery. The applications of machine learning (ML), mathematical optimization, and computer simulation have the potential to improve efficiency of TJA care delivery through outcome prediction and surgical scheduling optimization, easing the burden on health-care systems. The purpose of this study was to evaluate strategies using advances in analytics and computational modeling that may improve planning and the overall efficiency of TJA care. Methods: A systematic review including MEDLINE, Embase, and IEEE Xplore databases was completed from inception to October 3, 2022, for identification of studies generating ML models for TJA length of stay, duration of surgery, and hospital readmission prediction. A scoping review of optimization strategies in elective surgical scheduling was also conducted. Results: Twenty studies were included for evaluating ML predictions and 17 in the scoping review of scheduling optimization. Among studies generating linear or logistic control models alongside ML models, only 1 found a control model to outperform its ML counterpart. Furthermore, neural networks performed superior to or at the same level as conventional ML models in all but 1 study. Implementation of mathematical and simulation strategies improved the optimization efficiency when compared to traditional scheduling methods at the operational level. Conclusions: High-performing predictive ML-based models have been developed for TJA, as have mathematical strategies for elective surgical scheduling optimization. By leveraging artificial intelligence for outcome prediction and surgical optimization, there exist greater opportunities for improved resource utilization and cost-savings in TJA than when using traditional modeling and scheduling methods.

Impact of outpatient total hip or knee replacement on informal caregivers at home: a scoping review.

BACKGROUND: Although total hip arthroplasty (THA) and total knee arthroplasty (TKA) offer significant cost savings to our health care system, the degree to which the burden of postoperative care has been transferred onto the informal caregiver is often overlooked. We performed a scoping review to identify the characteristics and factors that contribute to the burden of care experienced after outpatient THA and TKA. METHODS: We systematically searched electronic literature databases according to scoping review guidelines from inception to June 2021 for articles reporting the experiences of informal caregivers providing care for patients having undergone outpatient THA or TKA. Our review included English-language studies that sought to elucidate the impact on caregivers in the acute postoperative period (up to 6 wk after surgery). RESULTS: Our search yielded 1423 unique articles, which were screened for inclusion. We removed 310 duplicate records and excluded another 1099 articles because they did not meet the inclusion criteria for full-text screening with relevancy. We thus assessed 14 articles for full-text review, and none were found to meet our inclusion criteria. CONCLUSION: We found no published data pertaining to the burden borne by informal caregivers who provide perioperative care to patients who have undergone ambulatory THA or TKA. Further research is needed to identify, quantify and determine the modifiability of the various characteristics and factors that contribute to caregiver burden in the outpatient setting.

Outcomes Following Total Hip Arthroplasty in Patients With Postpolio Syndrome: A Matched Cohort Analysis.

BACKGROUND: Patients with postpolio syndrome (PPS) may be afflicted by hip arthritis in either the paralytic or contralateral limb. Total hip arthroplasty (THA) may be considered in these patients. However, short-term and long-term outcomes following THA in PPS patients remain poorly characterized. METHODS: The PearlDiver MHip administrative database was queried for patients undergoing THA. Patients with a diagnosis of PPS were matched 1:4 with control patients on the basis of age, gender, and comorbidity burden. Incidence of postoperative adverse events and readmission in the 90 days following surgery and occurrence of revision arthroplasty in the five-year postoperative period were assessed between the two cohorts. RESULTS: In total, 1,519 PPS patients were matched to 6,076 control patients without PPS. After controlling for patient demographics and comorbidities, PPS patients demonstrated higher 90-day odds of urinary tract infection (odds ratio [OR] = 1.34, P = .016), pneumonia (OR = 2.07, P < .001), prosthetic dislocation (OR = 1.63, P = .018), and readmission (OR = 1.49, P = .002). Five years following surgery, 94.7% of the PPS cohort remained revision-free, compared to 96.7% of the control cohort (P = .001). CONCLUSION: Compared to patients without PPS, patients with PPS demonstrated a higher incidence of urinary tract infection, pneumonia, prosthetic dislocation, and hospital readmission. In addition, five-year incidence of revision arthroplasty was significantly higher among the PPS cohort. In light of these increased risks, special considerations should be made in both preoperative planning and postoperative surveillance of PPS patients undergoing THA. LEVEL OF EVIDENCE: Level III.

A Comparison of Acute Complications and Mortality Between Geriatric Knee and Hip Fractures: A Matched Cohort Study.

INTRODUCTION: To compare acute complication and mortality rates for operatively treated, closed, isolated, low-energy geriatric knee fractures (distal femur [DFF] or tibial plateau [TPF]) with hip fractures (HFs). METHODS: This is a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program. We identified all patients ≥ 70 years from 2011 to 2016 who underwent surgery for DFF, TPF, or HF. We recorded patient demographics, functional status, complications, and mortality. We matched DFF:TPF:HF patients on a 1:1:10 ratio based on age, sex, body mass index, baseline functional status, and comorbidity. We used the chi square, Fisher exact, and Mann Whitney U tests to compare unadjusted differences between groups and multivariable logistic regression to compare the risk of complications, readmission, or death while adjusting for relevant covariates. RESULTS: When compared with HF, patients in the DFF and TPF groups had longer length of stay and time to index surgery and were more likely to be discharged home. The rate of deep vein thrombosis was significantly higher in the TPF group (TPF = 3.9%, DFF = 1.3%, and HF = 1.2%, P = 0.005). CONCLUSION: Geriatric knee fractures pose a similar risk of acute complications, mortality, and readmission compared with patients with HF. Future studies investigating strategies to decrease risk in this patient cohort are warranted. LEVEL OF EVIDENCE: Therapeutic Level III.

Reducing Acute Hospitalization Length of Stay After Total Knee Arthroplasty: A Quality Improvement Study.

BACKGROUND: The introduction of bundled funding for total knee arthroplasty (TKA) has motivated hospitals to improve quality of care while minimizing costs. The aim of our quality improvement project is to reduce the acute hospitalization length of stay to less than 2 days and decrease the percentage of TKA patients discharged to inpatient rehabilitation using an enhanced recovery after surgery bundle. METHODS: This study used a before-and-after design. The pre-intervention period was January to December 2017 and the post-intervention period was January 2018 to August 2019. A root cause analysis was performed by a multidisciplinary team to identify barriers for rapid recovery and discharge. Four new interventions were chosen as part of an improvement bundle based on existing local practices, literature review, and feasibility analysis: (1) perioperative peripheral nerve block; (2) prophylactic antiemetic medication; (3) avoidance of routine preoperative urinary catheterization; and (4) preoperative patient education. RESULTS: The pre-intervention and post-intervention groups included 232 and 383 patients, respectively. Mean length of stay decreased from 2.82 to 2.13 days (P < .001). The need for inpatient rehabilitation decreased from 20.2% to 10.7% (P = .002). Mean 24-hour oral morphine consumption decreased from 60 to 38 mg (P < .001). The percentage of patients experiencing moderate-to-severe pain and postoperative nausea and vomiting within the first 24 hours decreased by 25% and 15%, respectively (P < .001). Thirty-day emergency department visits following discharge decreased from 12.9% to 7.3% (P = .030). CONCLUSION: Significant improvements in the recovery of patients after TKA were achieved by performing a root cause analysis and implementing a multidisciplinary, patient-centered enhanced recovery after surgery bundle. LEVEL OF EVIDENCE: Level III.

Management Options and Outcomes for Patients with Femoral Fractures with Post-Polio Syndrome of the Lower Extremity: A Critical Analysis Review.

Post-polio syndrome is characterized by a late functional deterioration (usually after >=15 years from the initial infection) in patients with a history of paralytic poliomyelitis infection, and it is defined by the March of Dimes criteria. Patients with post-polio syndrome are at increased risk for falls and associated hip and femoral fractures as a result of lower bone mineral density, decreased lean muscle mass, and musculoskeletal deformities. Current evidence suggests that treatment modalities for femoral fractures should emphasize fixation that allows early progressive weight-bearing and ambulation to optimize functional outcomes. Good results after hip arthroplasty have been described with both cemented and uncemented implants in patients who have been treated for osteoarthritis, but there has been little evidence guiding hip fracture management. Anatomic challenges that are encountered are osteoporotic bone, a valgus neck-shaft angle, increased femoral anteversion, and a small femoral canal diameter. Intramedullary nailing of hip and femoral fractures can be challenging due to the small femoral canal diameter that frequently is encountered. Alternative methods of fixation have shown promising results. These include the use of sliding hip screws for hip fracture management and fixed-angle locking plates for hip and femoral fracture management.

Evaluation of the Medial Stabilized Knee Design Using Data From National Joint Registries and Current Literature.

BACKGROUND: Various designs of total knee arthroplasty (TKA) have provided satisfactory outcomes for the treatment of knee osteoarthritis for many years. The aim of the study is to evaluate the success and failure rate of the medial stabilized (MS) TKA design through national joint registries and the current literature. MATERIALS AND METHODS: A comprehensive literature review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses was carried out through PubMed and MEDLINE database. The international registries analyzed included the National Joint Registry, the Australian Orthopedic Association National Joint Replacement Registry, the Dutch Arthroplasty Register, the New Zealand Orthopedic Association Joint Registry, and the Michigan Arthroplasty Registry Collaborative Quality Initiative. We are reporting descriptive data which include means and percentages of survival rates and revision rates and number of years after the primary procedure. The revision rates and the cumulative revision rates are reported separately for each MS implant. RESULTS: Our detailed review identified 5 of 12 registries and 25 of 550 studies reporting on the survivorship of an MS TKA design. There were a total of 3684 procedures between the 25 studies, with an average survivorship free of aseptic loosening of 99% at 6.9 years. There are 26,693 (2.5%) MS TKAs in the current National Joint Registry with a mean cumulative revision rate of 2.63% at 5 years, 3.35% at 10 years, and 4.6% at 15 years. The Australian Orthopedic Association National Joint Replacement Registry provides survivorship data on 19,249 (2.9%) MS TKAs, with a mean cumulative revision rate of 3.34% at 5 years, 7.4% at 10 years, and 8.1% at 15 years. The Dutch Arthroplasty Register contains survivorship data on 1490 MS designs and a mean revision rate of these implants is 0.8% at 1 year, 5.95% at 5 years, and 9.8% at 10 years. The Evolution MP is the only implant reported in the Michigan Arthroplasty Registry Collaborative Quality Initiative and has a revision rate of 2.28% at 3 years. CONCLUSION: The MS TKA design has comparable results to traditional TKA designs across several joint registries and 25 studies in the literature.

The Development of a Standardized Pathway for Outpatient Ambulatory Fracture Surgery: To Admit or Not to Admit.

BACKGROUND: Increased scrutiny of health-care costs and inpatient length of stay has resulted in many orthopaedic procedures transitioning to outpatient settings. Recent studies have supported the safety and efficiency of outpatient fracture procedures. The aim of the present study was to reduce unnecessary inpatient hospitalizations for healthy patients awaiting surgical treatment of a fracture by 80% by June 30, 2017, with a focus on timely, efficient, and patient-centered care. METHODS: The study design was a time series using statistical process control methodology. Baseline data from October 2014 to June 2016 were compared with the intervention period from July 2016 to December 2018. The Model for Improvement was used as the framework for developing and implementing interventions. The main interventions were a policy change to allow booking of outpatient urgent-room cases, education for patients and nurses, and the development of a standardized outpatient pathway. RESULTS: One hundred and eighty-seven patients during the pre-intervention period and 308 patients during the intervention period were eligible for the ambulatory pathway. The percentage of patients managed as outpatients increased from 1.6% pre-intervention to 89.1% post-intervention. The length of stay was reduced from 2.8 to 0.2 days, a decrease of 94.0%. Patient satisfaction remained high, and there were no safety concerns while patients waited at home for the surgical procedure. CONCLUSIONS: The outpatient fracture pathway vastly improved the efficiency and timeliness of care and reduced health-care costs. A patient-centered culture and support from hospital administration were integral in producing sustainable improvement. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Ideal Total Hip Replacement Bearing Surface in the Young Patient: A Prospective Randomized Trial Comparing Alumina Ceramic-On-Ceramic With Ceramic-On-Conventional Polyethylene: 15-Year Follow-Up.

BACKGROUND: The optimum bearing surface for total hip arthroplasty remains debatable. We have previously published our outcome at 10 years and this represents the 15-year follow-up. METHODS: A total of 58 hips (in 57 patients with a mean age of 42 years) were randomized to receive either ceramic-on-ceramic (CoC) or ceramic-on-polyethylene (CoP) total hip arthroplasty. We prospectively followed for survivorship, functional outcomes (using the Harris Hip Score and the St Michael's Hip Score [SMH]), and radiological outcomes. RESULTS: At a minimum of 15 years, 3 patients had died, but not been revised. Seven were lost to follow-up. Five cases from the CoP group were revised (4 for polyethylene wear and osteolysis). Four from the CoC were revised; one each for head fracture, instability, infection, and trunnionosis. Both groups showed statistically significant improvements in Harris Hip Score scores and SMH functional scores, with no difference between the 2 bearings. For the CoP group, there was an improvement from 15.6 to 21.5 in the SMH and from 48.8 to 88.7 (P > .05); and for CoC, this improvement was 15.8 to 23.5 and 50.3 to 94.6 (P > .05), respectively. Mean wear rate of the polyethylene was 0.092 mm/y and for the CoC was 0.018 mm/y. Two patients in the CoC group had evidence of acetabular osteolysis vs 3 in the CoP. Six patients had femoral osteolysis in the CoC group and 12 in the CoP group. CONCLUSION: Survivorship and function of the 2 bearing groups remains comparable; while the polyethylene wear and osteolysis may represent issues in the future.

A Retrospective Comparison of a Medial Pivot and Posterior-Stabilized Total Knee Arthroplasty With Respect to Patient-Reported and Radiographic Outcomes.

BACKGROUND: Medial pivot (MP) type total knee arthroplasty (TKA) implants are designed with a highly congruent medial tibiofemoral articulation. Compared with the cam-and-post design of the posterior-stabilized (PS) TKA, the MP-TKA design has been hypothesized to better replicate the natural kinematics of the knee. We compared the MP-TKA and PS-TKA designs, with our primary outcome measures being range of motion (ROM) and patient-reported satisfaction. METHODS: This study was a retrospective comparison between the 2 groups (76 MP-TKA vs 88 PS-TKA). ROM was collected preoperatively, 6 weeks, 6 months, and 1 year postoperatively. The Forgotten Joint Score-12 (FJS-12) scores were collected at a minimum of 1 year postoperatively. RESULTS: There was no statistically significant difference in age, gender, or body mass index between the groups. We found a statistical difference in preoperative ROM (MP = 120.3°, PS = 112.8°, P = .002). There was no difference in ΔROM at 6 weeks (MP = -12.36, PS = -3.79, P = .066), 6 months (MP = -4.23, PS = 2.73, P = .182), or 1 year (MP = .17, PS = 3.31, P = .499). Patients who underwent the MP-TKA scored significantly better than the PS-TKA on the FJS-12 score (MP = 59.72, PS = 44.77, P = .007). CONCLUSION: We found that patients who underwent the MP-TKA scored better on the FJS than those who underwent the PS-TKA; particularly with regard to deep knee flexion and stability of the prosthesis. The MP-TKA design may offer improved patient outcomes because of its highly congruent medial tibiofemoral articulation.

Current concepts: the role of mesenchymal stem cells in the management of knee osteoarthritis.

CONTEXT: The number of adults with osteoarthritis in the United States is expected to nearly double from 21.4 million in 2005 to 41.1 million by 2030. As a result, medical costs and associated comorbidity will exponentially increase in the coming decades. In the past decade, mesenchymal stem cells (MSCs) have emerged as a novel treatment for degenerative joint disease. EVIDENCE ACQUISITION: PubMed (from 1990 to 2013) was searched to identify relevant studies. Reference lists of included studies were also reviewed. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 3. RESULTS: We identified 9 animal and 7 human studies investigating the use of MSCs in the treatment of osteoarthritis, with varying levels of support for this therapy. CONCLUSION: While MSCs have shown potential for improving function and decreasing inflammation in animal studies, translation to patients is still in question. There is a great deal of heterogeneity in treatment methods. Standardizing the manufacturing and characterization of MSCs will allow for better comparisons.

Herceptin, a recombinant humanized anti-ERBB2 monoclonal antibody, induces cardiomyocyte death.

P53 protein levels are elevated by trastuzumab and the biologically similar rat ERBB2/HER2/NEU antibody; and that this coincides with enhanced apoptosis, increased cleaved caspase-3 levels and diminished cardiac function. We also demonstrate that MDM2 may be a regulatory target of anti-ERBB2 thereby implicating the MDM2/p53 axis as a potential molecular component for the undesirable cardiac outcomes noted with trastuzumab. Finally, we show that these MDM2/p53-mediated events are independent of both the ERK1/2 and Akt systems. In conclusion, our findings suggest that the adverse cardiac events observed with trastuzumab may stem from its negative regulation of MDM2 events which impairs p53 degradation resultantly promoting apoptosis leading to cardiac dysfunction. These observations may have important therapeutic implications since they suggest that anticancer agents that inhibit MDM2 and its downstream actions may curb tumor progression at the expense of increasing cardiac stress.

The effect of computerized physician order entry with clinical decision support on the rates of adverse drug events: a systematic review.

CONTEXT: Computerized physician order entry (CPOE) with clinical decision support (CDS) has been promoted as an effective strategy to prevent the development of a drug injury defined as an adverse drug event (ADE). OBJECTIVE: To systematically review studies evaluating the effects of CPOE with CDS on the development of an ADE as an outcome measure. DATA SOURCES: PUBMED versions of MEDLINE (from inception through March 2007) were searched to identify relevant studies. Reference lists of included studies were also searched. METHODS: We searched for original investigations, randomized and nonrandomized clinical trials, and observational studies that evaluated the effect of CPOE with CDS on the rates of ADEs. The studies identified were assessed to determine the type of computer system used, drug categories being evaluated, types of ADEs measured, and clinical outcomes assessed. RESULTS: Of the 543 citations identified, 10 studies met our inclusion criteria. These studies were grouped into categories based on their setting: hospital or ambulatory; no studies related to the long-term care setting were identified. CPOE with CDS contributed to a statistically significant (P < or = .05) decrease in ADEs in 5 (50.0%) of the 10 studies. Four studies (40.0%) reported a nonstatistically significant reduction in ADE rates, and 1 study (10.0%) demonstrated no change in ADE rates. CONCLUSIONS: Few studies have measured the effect of CPOE with CDS on the rates of ADEs, and none were randomized controlled trials. Further research is needed to evaluate the efficacy of CPOE with CDS across the various clinical settings.