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Mu T, Yuan B, Wei K, Yang Q. Adductor canal block combined with genicular nerve block versus local infiltration analgesia for total knee arthroplasty: a randomized noninferiority trial. J Orthop Surg Res 2024; 19:546. [PMID: 39238029 PMCID: PMC11378376 DOI: 10.1186/s13018-024-05048-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2024] [Accepted: 09/01/2024] [Indexed: 09/07/2024] Open
Abstract
OBJECTIVE This randomized controlled and double-blind study aimed to investigate whether the analgesic effect of the adductor canal block (ACB) combined with the genicular nerve block (GNB) after total knee arthroplasty is noninferior to that of the adductor canal block combined with local infiltration analgesia (LIA). METHODS A total of 102 patients undergoing total knee arthroplasty under general anesthesia were included and randomly divided into: ACB + GNB and ACB + LIA groups; the ACB + LIA group received 80 mL of 0.2% ropivacaine with adrenaline 10 µg/mL for LIA, whereas the ACB + GNB group received 4 mL of 0.2% ropivacaine for the blockade of five peri-knee nerves. The primary outcome was the median difference in the visual analog scale scores at rest at 24 h between the two groups. Secondary outcomes involved the median differences in the pain scores at other time points. Other outcomes included the cumulative dosage of opioids calculated in morphine equivalents in the first 24 h and indicators related to knee joint functional recovery. RESULTS In total, 36 and 38 patients were included in the ACB + GNB and ACB + LIA groups, respectively. We found that the median difference (95% confidence internal) in postoperative rest pain at 24 h (noninferiority criteria, △ = 1) was - 0.5 (- 1 to 0, p = 0.002). The median difference in cumulative opioid consumption was 1 mg (- 1 to 3, p = 0.019), meeting the noninferiority criteria, △ = 7.7 mg. CONCLUSIONS ACB combined with GNB provides noninferior analgesia compared to ACB with LIA on the first day after total knee arthroplasty while significantly reducing local anesthetic use. TRIAL REGISTRATION Name of the Registry: Chinese Clinical Trial Registry; Trial Registration Number: ChiCTR2300074274; Date of Registration. August 2, 2023.
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Affiliation(s)
- Tong Mu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China
| | - Baohong Yuan
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China.
| | - Ke Wei
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China
| | - Qian Yang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China
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Clapp IM, Orton C, Kapron C, Blackburn B, Gililland JM, Anderson LA, Pelt CE, Peters CL, Archibeck MJ. Conversion of Tibial Plateau Fractures to Total Knee Arthroplasty is Associated with Worse Patient-Reported Outcomes, Increased Operative Time and Increased Complications. J Arthroplasty 2024:S0883-5403(24)00912-4. [PMID: 39233105 DOI: 10.1016/j.arth.2024.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 08/27/2024] [Accepted: 08/29/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Prior open reduction and internal fixation (ORIF) of tibial plateau fracture (TPF) adds complexity to subsequent total knee arthroplasty (TKA). The purpose of this study was to compare the outcomes of patients undergoing a TKA following prior ORIF of TPF to patients undergoing a primary TKA for osteoarthritis and an aseptic revision TKA. METHODS There were 52 patients who underwent primary TKA following prior ORIF of TPF between January 2009 and June 2021, who were included and matched in a 1:4 ratio by sex, body mass index, and American Society of Anesthesiologists class to 208 patients undergoing primary TKA. A second 1:1 matched comparison to 52 aseptic revision TKA patients was also included. The Knee injury and Osteoarthritis Outcome Score for Joint Replacement scores were obtained preoperatively and at 2-years postoperatively. Independent t-tests and Chi-square tests were used for statistical comparisons. RESULTS The TPF patients were significantly younger than both the primary and revision cohorts (55 ± 14.0 versus 63 ± 16.3 versus 64 ± 9.5, P < 0.001). Compared to primary TKA patients, the TPF group had worse KOOS JR scores at 2-years (46.9 ± 18.5 versus 66.2 ± 17.8, P = 0.0152), higher rates of wound complications (15.4 versus 3.9%, P = 0.0020), and increased operative times (140.2 ± 45.3 versus 95.2 ± 25.7, P < 0.0001). No significant differences in these metrics were seen between the TPF group and the revision group. Additionally, TPF patients were more likely to require a manipulation under anesthesia (MUA) than both primary and revision patients (21.2 versus 5.8 versus 5.8%, P = 0.001). CONCLUSION The TKAs following ORIF of TPF are more like revision TKAs than primary TKAs in terms of patient-reported outcomes, operative times, and wound complications. The rate of MUA was higher than in both matched groups. These findings provide valuable information that can affect preoperative patient education and postoperative management regimens for these patients. They also emphasize the need for a conversion to TKA code due to the increased complexity and complications seen in this more difficult subset of TKAs.
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Affiliation(s)
- Ian M Clapp
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah.
| | - Cody Orton
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Claire Kapron
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Brenna Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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Syrikas I, Engbäck C, Tsikandylakis G, Karikis I, Desai N. Increased complications rates and inferior patient reported outcomes following total knee arthroplasty due to post-traumatic osteoarthritis with previous fracture treatment: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:4124-4141. [PMID: 37097470 PMCID: PMC10471648 DOI: 10.1007/s00167-023-07407-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 03/26/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE This study aims to present the existing literature relating to patient-reported outcome measures (PROMs) and complications in patients undergoing total knee arthroplasty (TKA) due to posttraumatic osteoarthritis (PTOA) with prior fracture treatment around the knee compared with patients who underwent TKA because of primary osteoarthritis (OA). METHODS A systematic review was undertaken and synthesised in accordance with the PRISMA guidelines by searching existing literature in the following databases: PubMed, Scopus, Cochrane Library and EMBASE. A search string according to the PECO was used. After analysing 2781 studies, 18 studies (5729 PTOA patients/149,843 OA patients) were included for a final review. An analysis revealed that 12 (67%) were retrospective cohort studies, four (22%) were register studies and the remaining two (11%) were prospective cohort studies. The mean Critical Appraisal Skills Programme (CASP) score was 23.6 out of 28, signifying studies of moderate quality. RESULTS The most frequently reported outcome measure were postoperative complications, reported in all eighteen studies. Intraoperative complications were reported in ten (4165 PTOA/124.511 OA) and patient-reported outcome measures (PROMs) in six studies (210 PTOA/2768 OA). A total of nine different PROMs were evaluated. As far as PROMs were concerned, the scores were inferior for PTOA but did not differ statistically from OA, except for one study, which favoured the OA group. Across all studies, postoperative complications were higher in the PTOA group, reporting infections as the most common complication. Furthermore, a higher revision rate was reported in the PTOA group. CONCLUSION PROM analysis suggests that both patient groups benefit from a TKA in terms of functional outcome and pain relief, however, patient-reported outcomes could be inferior for PTOA patients. There is consistent evidence for increased complication rates following PTOA TKA. Patients undergoing TKA due to PTOA after fracture treatment should be informed about the risk for inferior results and refrain from comparing their knee function to patients with TKA after OA. Surgeons should be aware of the challenges that PTOA TKA poses. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ioannis Syrikas
- Department of Orthopaedics, NU-Hospital Group, Trollhättan/Uddevalla, Sweden.
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Cecilia Engbäck
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Georgios Tsikandylakis
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Ioannis Karikis
- Department of Orthopaedics, NU-Hospital Group, Trollhättan/Uddevalla, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Research and Development, NU-Hospital Group, Trollhättan, Sweden
| | - Neel Desai
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
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Bormann M, Neidlein C, Neidlein N, Ehrl D, Jörgens M, Berthold DP, Böcker W, Holzapfel BM, Fürmetz J. High Prevalence of Persistent Measurable Postoperative Knee Joint Laxity in Patients with Tibial Plateau Fractures Treated by Open Reduction and Internal Fixation (ORIF). J Clin Med 2023; 12:5580. [PMID: 37685647 PMCID: PMC10488731 DOI: 10.3390/jcm12175580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
The development of post-traumatic osteoarthrosis after tibial plateau fracture (TPF) is multifactorial and can only be partially influenced by surgical treatment. There is no standardized method for assessing pre- and postoperative knee joint laxity. Data on the incidence of postoperative laxity after TPF are limited. The purpose of this study was to quantify postoperative laxity of the knee joint after TPF. Fifty-four patients (mean age 51 ± 11.9 years) were included in this study. There was a significant increase in anterior-posterior translation in 78.0% and internal rotation in 78.9% in the injured knee when compared to the healthy knee. Simple fractures showed no significant difference in laxity compared to complex fractures. When preoperative ligament damage and/or meniscal lesions were present and surgically treated by refixation and/or bracing, patients showed higher instability when compared to patients without preoperative ligament and/or meniscal damage. Patients with surgically treated TPF demonstrate measurable knee joint laxity at a minimum of 1 year postoperatively. Fracture types have no influence on postoperative laxity. This emphasizes the importance of recognizing TPF as a multifaceted injury involving both complex fractures and damage to multiple ligaments and soft tissue structures, which may require further surgical intervention after osteosynthesis.
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Affiliation(s)
- Markus Bormann
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Claas Neidlein
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Niels Neidlein
- Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Dennis Ehrl
- Department of Hand, Plastic and Aesthetic Surgery, LMU Munich, 81377 Munich, Germany
| | - Maximilian Jörgens
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Daniel P. Berthold
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Wolfgang Böcker
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Boris Michael Holzapfel
- Department of Orthopaedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Marchioninistraße 15, 81377 Munich, Germany
| | - Julian Fürmetz
- Department of Trauma Surgery, Trauma Center Murnau, 82418 Murnau am Staffelsee, Germany
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Pavão DM, Heringer EM, Almeida GJ, de Faria JLR, Pires e Albuquerque RS, de Sousa EB, Labronici PJ. Predictive and protective factors for allogenic blood transfusion in total knee arthroplasty. A retrospective cohort study. J Orthop 2023; 40:29-33. [PMID: 37159823 PMCID: PMC10163608 DOI: 10.1016/j.jor.2023.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/11/2023] Open
Abstract
Background This study aimed to identify the predictive and protective factors of blood transfusion in patients undergoing total knee arthroplasty (TKA) and therefore determine the profile of patients with low and high risk of blood transfusion after arthroplasty. Methods We conducted a retrospective study with all patients who underwent primary TKA between January 2017 and December 2019 (n = 1.028 patients) in our institution. Information about allogenic transfusion was collected from medical records to determine the incidence, the predictive and protective factors of blood transfusion. All cases of blood transfusions were documented as well the number of units and the moment of each transfusion. We performed univariate and multivariate logistic regression analyses to identify the independent risk and protective factors. Results The total transfusion rate was 11%, 1.1% at intraoperative and 9,9% at postoperative period. The independent risk factors for transfusion were female gender (OR 1.64), older age (>55yo, OR > 2) higher surgical risk (ASA III, OR 3.07), lower preoperative hemoglobin levels (p = 0.024), post-traumatic arthritis (OR 4.11) and use of postoperative drains (OR 1.81) The protective factors for transfusion were male gender (OR 0.60), obesity (IMC >30, OR 0.60) and use of intravenous tranexamic acid intraoperatively (OR 0.40). Conclusions We conclude that in addition to the well-established risk factors for blood transfusion such as advanced age, low hemoglobin levels and high surgical risk, we can add post-fracture arthroplasty, non-use of tranexamic acid and the use of postoperative joint drain.
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Affiliation(s)
- Douglas Mello Pavão
- National Institute of Traumatology and Orthopaedics (INTO), Rio de Janeiro, Brazil
- Federal Fluminense University (UFF), Niteroi, Brazil
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Apinyankul R, Hui AY, Hwang K, Segovia NA, Amanatullah DF, Huddleston JI, Maloney WJ, Goodman SB. Complications, Implant Survivorships, and Functional Outcomes of Conversion Total Knee Arthroplasty With Prior Hardware. J Arthroplasty 2023; 38:S66-S70.e2. [PMID: 36758842 DOI: 10.1016/j.arth.2023.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND End-stage knee osteoarthritis with retained periarticular hardware is a frequent scenario. Conversion total knee arthroplasty (TKA) leads to excellent outcomes, but poses unique challenges. The evidence supporting retention versus removal of hardware during TKA is controversial. METHODS Patients who underwent TKA with prior hardware between January 2009 and December 2019 were identified. A total of 148 patients underwent TKA with prior hardware. The mean follow-up was 60 months (range, 24-223). Univariate and multivariable analyses were used to study correlations among factors and surgical-related complications, prosthesis failures, and functional outcomes. RESULTS The complication rate was 28 of 148 (18.9%). The use of a quadriceps snips in addition to a medial parapatellar arthrotomy was associated with a higher complication (odds ratio: 20.7, P < .05), implant failures (odds ratio: 13.9, P < .05), and lower the Veterans Rand 12 Mental Score (VR-12 MS) (-14.8, P < .05). Hardware removal versus retention and use of single versus multiple incisions were not associated with complications or prosthesis failures. Removal of all hardware was associated with significantly higher (+7.3, P < .05) VR-12 MS compared to retention of all hardware. CONCLUSIONS TKA with prior hardware was associated with more complications, implant failures, and lower VR-12 MS when a more constrained construct or quadriceps snip was performed. This probably reflects the level of difficulty of the procedure rather than the surgical approach used. Hardware removal or retention was not associated with complications or implant failures; however, removal rather than retention of all prior hardware is associated with increased general health outcomes. LEVEL OF EVIDENCE IV, cohort without control.
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Affiliation(s)
- Rit Apinyankul
- Department of Orthopaedics, Khon Kaen University, Khon Kaen, Thailand
| | - Alexander Y Hui
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Stanford University School of Medicine, Stanford, California
| | - Katherine Hwang
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Stanford University School of Medicine, Stanford, California
| | - Nicole Alexandriadria Segovia
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Stanford University School of Medicine, Stanford, California
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Stanford University School of Medicine, Stanford, California
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Stanford University School of Medicine, Stanford, California
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Stanford University School of Medicine, Stanford, California
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University Medical Center Outpatient Center, Stanford University School of Medicine, Stanford, California
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Total knee arthroplasty in post-traumatic osteoarthritis is more challenging, but results in similar patient satisfaction - An analysis of 1646 cases. Knee 2022; 39:116-123. [PMID: 36191398 DOI: 10.1016/j.knee.2021.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 11/02/2021] [Accepted: 12/14/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients with post-traumatic osteoarthritis (PTOA) present a variety of technical challenges to surgeons. Surgical parameters, complication rates and patient-reported outcomes (PROs) have been reported as detrimental in total knee arthroplasty (TKA) for PTOA. The purpose of this study was to compare these variables and satisfaction with the results of TKA in patients with post-traumatic osteoarthritis with a matched-pair cohort of primary osteoarthritis (POA). METHODS A registry-embedded prospective case-control study was performed. Of a total of 1646 TKAs, 155 were performed due to PTOA between 2012 and 2019. One-hundred and thirty-six could be one-to-one propensity score-matched to patients with POA undergoing primary TKA based on similar patient demographic variables. Outcomes investigated included operation time, estimated blood loss, types of implants, postoperative complications and PROs pre- and 1 year postoperatively as well as satisfaction with the results of surgery. Sub-cohort analysis was performed for patients with prior fracture and soft tissue trauma, respectively. RESULTS Surgical parameters were significantly different in disadvantages of PTOA: operation time (P < 0.001), estimated blood loss (P < 0.001), blood transfusions (P = 0.039), type of implants (P < 0.001). Manipulation under anaesthesia (MUA) was necessary more often in the PTOA fracture group (odds ratio 5.01, (95% confidence interval 1.04; 24.07). PRO demonstrated no substantial differences after 1 year. Satisfaction with the results of TKA was as equally high in all cohorts. CONCLUSIONS This study demonstrated that TKAs in patients with PTOA require higher surgical effort but can result in similar PROs and satisfaction compared to POA, regardless of the underlying trauma.
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Malhotra R, Jain A, Gupta S, Gautam D. Outcomes of Total Knee Arthroplasty in Patients with Prior Hardware: A Case-Control Study Using Handheld Navigation. J Knee Surg 2022; 35:1474-1483. [PMID: 33853153 DOI: 10.1055/s-0041-1726419] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Presence of hardware in juxta-articular location poses challenge during total knee arthroplasty (TKA). When present in distal femur, it precludes the use of an intramedullary femoral jig during TKA often necessitating removal of hardware leading to prolonged surgery, higher risk of complications, and inferior results. We conducted a case-control study to assess the outcome of TKA among patients with post-traumatic arthritis using a handheld navigation system to perform bone cuts allowing retention of hardware in situ. In 15 patients with post-traumatic arthritis and hardware around the knee (Group A), none or part(s) of hardware were removed while performing TKA. These patients were matched to 15 patients who underwent TKA with handheld navigation for primary OA knee (Group B). The perioperative outcomes assessed were operative time, intraoperative blood loss, length of hospital stay, complications, and 30 days reoperation rate. Clinical outcomes were assessed by using Knee Society Score (KSS) and radiological outcomes using mechanical axis and coronal and sagittal component angles. Mean age of patients at surgery were 65.67 years (Group A) and 66.73 years (Group B). Mean operative time and blood loss were significantly higher in Group A as compared with Group B. At the mean follow-up of 34 months, KSS significantly improved in both the groups. However, there was no statistically significant difference in the clinical and radiological outcomes between the two groups. One patient in Group A developed wound dehiscence and had to undergo debridement and flap coverage within 30 days. The use of navigation helps surgeons in gaining proper limb alignment and implant positioning without complete removal of hardware.
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Affiliation(s)
- Rajesh Malhotra
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Aditya Jain
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gautam
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
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Butorphanol as an Adjuvant to Ropivacaine for Adductor Canal Blocks in Total Knee Arthroplasty Patients: A Randomized, Double, Blind Study. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7718108. [PMID: 36275396 PMCID: PMC9586814 DOI: 10.1155/2022/7718108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022]
Abstract
Background The objective of this study was to observe the effects of butorphanol as an adjuvant to ropivacaine for the adductor canal block (ACB) on postoperative analgesia in patients undergoing total knee arthroplasty (TKA). Methods Seventy-four patients undergoing TKA were included and randomly divided into two groups: Group BR received 20 ml of 0.33% ropivacaine plus 1 mg butorphanol and Group R received 20 ml of 0.33% ropivacaine plus 1 ml normal saline for ultrasound-guided adductor canal blocks. The primary outcomes were the duration of the sensory block and the pain visual analogue scale (VAS), and secondary outcomes included the number of PCIA attempts (patient-controlled intravenous analgesia) and the time to first pressing and rescue analgesia. Other outcomes included knee active range of motion (ROM), quadriceps strength, the time to first mobilization, the duration of postoperative hospital stay, Knee Society Score (KSS), and postoperative complications. Results Since two patients in each group rejected postoperative assessments, 35 patients were included in each group. Compared with Group R, Group BR had longer duration of sensory blocks (18.42 ± 3.46 vs. 15.36 ± 2.29 h, p < 0.01) and lower postoperative pain scores within 24 hours at rest and within 12 hours with activity (p < 0.01). The number of PCIA attempts decreased within 48 hours after surgery (4.5 ± 1.2 vs. 7.8 ± 1.5 times, p < 0.01), and the time to first pressing was later (20.31 ± 2.59 vs. 16.25 ± 2.31 h, p < 0.01). In addition, Group BR had bigger knee ROM at within 24 hours after the operation than Group R (68.37 ± 4.70°vs. 59.21 ± 6.41,85.67 ± 5.17 vs. 74.37 ± 4.68°, 97.62 ± 5.43 vs. 84.18 ± 4.49°, p < 0.01). There was no significant difference between the two groups (p > 0.05) in terms of rescue analgesia, quadriceps strength, the time to first mobilization, the duration of postoperative hospital stay, the KSS function scores, and postoperative complications. Conclusions Butorphanol plus ropivacaine ultrasound-guided adductor canal block can prolong the duration of sensory block, relieve early postoperative pain, and improve the range of motion of the knee joint, without affecting the occurrence of postoperative complications. Name of the Registry. Chinese Clinical Trial Registry. Trial Registration Number. ChiCTR2100041859. URL of Trial Registry Record. http://www.chictr.org.cn/edit.aspx?pid=119731&htm=4. Date of Registration. 08/01/2021 0:00:00.
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Fan WJ, Liu D, Pan LY, Wang WY, Ding YL, Zhang YY, Ye RX, Zhou Y, An SB, Xiao WF. Exosomes in osteoarthritis: Updated insights on pathogenesis, diagnosis, and treatment. Front Cell Dev Biol 2022; 10:949690. [PMID: 35959489 PMCID: PMC9362859 DOI: 10.3389/fcell.2022.949690] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 07/04/2022] [Indexed: 01/09/2023] Open
Abstract
Osteoarthritis (OA) has remained a prevalent public health problem worldwide over the past decades. OA is a global challenge because its specific pathogenesis is unclear, and no effective disease-modifying drugs are currently available. Exosomes are small and single-membrane vesicles secreted via the formation of endocytic vesicles and multivesicular bodies (MVBs), which are eventually released when MVBs fuse with the plasma membrane. Exosomes contain various integral surface proteins derived from cells, intercellular proteins, DNAs, RNAs, amino acids, and metabolites. By transferring complex constituents and promoting macrophages to generate chemokines and proinflammatory cytokines, exosomes function in pathophysiological processes in OA, including local inflammation, cartilage calcification and degradation of osteoarthritic joints. Exosomes are also detected in synovial fluid and plasma, and their levels continuously change with OA progression. Thus, exosomes, specifically exosomal miRNAs and lncRNAs, potentially represent multicomponent diagnostic biomarkers for OA. Exosomes derived from various types of mesenchymal stem cells and other cell or tissue types affect angiogenesis, inflammation, and bone remodeling. These exosomes exhibit promising capabilities to restore OA cartilage, attenuate inflammation, and balance cartilage matrix formation and degradation, thus demonstrating therapeutic potential in OA. In combination with biocompatible and highly adhesive materials, such as hydrogels and cryogels, exosomes may facilitate cartilage tissue engineering therapies for OA. Based on numerous recent studies, we summarized the latent mechanisms and clinical value of exosomes in OA in this review.
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Affiliation(s)
- Wen-Jin Fan
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Di Liu
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
| | - Lin-Yuan Pan
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
| | - Wei-Yang Wang
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Yi-Lan Ding
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Yue-Yao Zhang
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Rui-Xi Ye
- Xiangya School of Medicine, Central South University, Changsha, China
| | - Yang Zhou
- Department of Clinical Nursing, Xiangya Hospital, Central South University, Changsha, China,*Correspondence: Yang Zhou, ; Sen-Bo An, ; Wen-Feng Xiao,
| | - Sen-Bo An
- Department of Orthopaedics, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China,*Correspondence: Yang Zhou, ; Sen-Bo An, ; Wen-Feng Xiao,
| | - Wen-Feng Xiao
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China,*Correspondence: Yang Zhou, ; Sen-Bo An, ; Wen-Feng Xiao,
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11
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Chen Z, Sax OC, Bains SS, Hebditch CS, Nace J, Delanois RE. Is Conversion Total Knee Arthroplasty a Distinct Surgical Procedure? A Comparison to Primary and Revision Total Knee Arthroplasty. J Knee Surg 2022. [PMID: 35798340 DOI: 10.1055/s-0042-1750059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Conversion total knee arthroplasty (TKA) is suggested to incur similar complication rates to revision arthroplasties. However, current billing codes do not allow for the differentiation between this operation and primary TKAs. Therefore, the purpose of this study was to compare outcomes of these two surgeries, as well as revision TKAs. Specifically, we analyzed (1) medical complications, (2) surgical complications, and (3) revision rates at 90 days and 1 year. We queried a national, all-payer database to identify patients who underwent TKA without prior implants (n = 1,358,767), required conversion TKA (n = 15,378), and who underwent revision TKA (n = 33,966) between January 1, 2010, and April 30, 2020. Conversion TKA patients (prior implant removal) were identified using the Current Procedural Terminology (CPT) codes. Outcomes studied included 30-day readmission rates and 90-day, as well as 1-year, medical and surgical complications. Conversion TKAs had greater 30-day readmission rates and incidences of most of the complications studied when compared with primary TKAs. The majority of outcomes when comparing between primary, conversion, and revision TKAs were significantly different (p < 0.01). In contrast, conversion TKA complications were similar to revision TKA. Conversion TKAs have higher postoperative complications than primary TKAs and share more similarities with revision TKAs. Thus, the lack of billing codes differentiating conversion and primary TKAs creates a challenge for orthopaedic surgeons.
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Affiliation(s)
- Zhongming Chen
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Oliver C Sax
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep S Bains
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Cameron S Hebditch
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - James Nace
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Center for Joint Preservation and Replacement, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Shapira J, Abu Elasal A, Ghrayeb N, Nierenberg G. Multiple trauma-induced, secondary osteoarthritis, knee Arthroplasty and technology: Conventional approach to an unconventional scenario. BMJ Case Rep 2022; 15:e245263. [PMID: 35131774 PMCID: PMC8823041 DOI: 10.1136/bcr-2021-245263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 11/03/2022] Open
Abstract
A 49-year-old man was involved in a high-energy motor vehicle accident. Haemodynamic instability with multiple long bone fractures of lower limbs was the hallmarks of the injury. Closed fragmented fracture of left femur shaft and open displaced supracondylar fracture of the contralateral femur. Closed comminuted high-grade fracture of the Tibia plateau (Schatzker VI) was diagnosed bilaterally. 'Orthopaedic damage control' was initiated with bilateral 'cross knee' external fixation, followed by conversion to open reduction internal fixation of all fracture sits at 8 days later. The patient underwent nine subsequent hospitalisations, of which eight involved operative treatment. The interval from admission to last documented surgery was 7 years. The endpoint was total knee arthroplasty (TKA) with mega prosthesis of the left knee and a primary-type TKA in the right knee. Both arthroplasties were non-assisted, conventional procedures. Postoperative Western Onterio and McMaster Universities Arthritis Index (WOMAC) score was 85 at 9-year follow-up from the injury incurred.
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Affiliation(s)
- Jacob Shapira
- Orthpaedics, Rambam Health Care Campus, Haifa, Israel
| | | | - Nabil Ghrayeb
- Orthpaedics, Rambam Health Care Campus, Haifa, Israel
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13
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Stake SN, Gu A, Fassihi SC, Ramamurti P, Bovonratwet P, Thakkar SC, Golladay GJ. Increased Revisions in Conversion Total Knee Arthroplasty After Periarticular Open Reduction Internal Fixation Compared With Primary Total Knee Arthroplasty: A Matched Cohort Analysis. J Arthroplasty 2021; 36:3432-3436.e1. [PMID: 34099349 DOI: 10.1016/j.arth.2021.05.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/08/2021] [Accepted: 05/12/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prior studies on conversion total knee arthroplasty (cTKA) have reported increased technical challenges and risk of complications compared with primary knee arthroplasty. The purpose of this study was to compare two-year postoperative complication/revision rates between patients undergoing cTKA after prior periarticular open reduction and internal fixation (ORIF) and those undergoing primary TKA. METHODS Patients who underwent cTKA after prior periarticular ORIF of the ipsilateral knee were identified in a national all-payer claims database from 2010 to 2018. This ORIF-cTKA cohort was propensity matched to participants undergoing primary TKA based on age, gender, Charlson comorbidity index, and obesity status. Univariate analysis was performed to analyze differences in two-year complication and revision rates. RESULTS After propensity matching, 823 patients were included in the ORIF-cTKA cohort and 1640 patients in the primary TKA cohort. No differences in demographics or comorbidities existed between cohorts. Relative to the primary TKA cohort, the ORIF-cTKA cohort had significantly higher incidences of all-cause revision (5.47% vs 2.47%, P = .001), periprosthetic joint infection (PJI; 4.74% vs 1.34%, P < .001), and intraoperative or postoperative periprosthetic fracture (1.58% vs 0.55%, P = .01) at two years postoperatively. There was also a nonsignificant trend toward increased rates of aseptic loosening (1.82% vs 0.91%, P = .052) in the ORIF-cTKA. CONCLUSION Relative to primary TKA, cTKA after periarticular ORIF is associated with significantly increased rates of all-cause revision, PJI, and periprosthetic fracture at two years postoperatively. Surgeons should counsel these patients about the increased risks of these postoperative complications and consider treating them as high risk for PJI in the perioperative period.
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Affiliation(s)
- Seth N Stake
- Department of Orthopaedic Surgery; The George Washington University Hospital, WA
| | - Alex Gu
- Department of Orthopaedic Surgery; The George Washington University Hospital, WA
| | - Safa C Fassihi
- Department of Orthopaedic Surgery; The George Washington University Hospital, WA
| | - Pradip Ramamurti
- Department of Orthopaedic Surgery; The George Washington University Hospital, WA
| | - Patawut Bovonratwet
- Department of Orthopaedic Surgery; Hospital for Special Surgery, New York, NY
| | - Savyasachi C Thakkar
- Department of Orthopedic Surgery, Johns Hopkins Department of Orthopaedic Surgery, Columbia, MD
| | - Gregory J Golladay
- Department of Orthopedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
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Ramamurti P, Fassihi SC, Stake S, Stadecker M, Whiting Z, Thakkar SC. Conversion Total Knee Arthroplasty. JBJS Rev 2021; 9:01874474-202109000-00007. [PMID: 34812774 DOI: 10.2106/jbjs.rvw.20.00198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Conversion total knee arthroplasty (TKA) represents a heterogeneous group of procedures and most commonly includes TKA performed after ligamentous reconstruction, periarticular open reduction and internal fixation (ORIF), high tibial osteotomy (HTO), and unicompartmental knee arthroplasty (UKA). » Relative to patients undergoing primary TKA, patients undergoing conversion TKA often have longer operative times and higher surgical complexity, which may translate into higher postoperative complication rates. » There is mixed evidence on implant survivorship and patient-reported outcome measures when comparing conversion TKA and primary TKA, with some studies noting no differences between the procedures and others finding decreased survivorship and outcome scores for conversion TKA. » By gaining an improved understanding of the unique challenges facing patients undergoing conversion TKA, clinicians may better set patient expectations, make intraoperative adjustments, and guide postoperative care.
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Affiliation(s)
- Pradip Ramamurti
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Safa C Fassihi
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Seth Stake
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Monica Stadecker
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Zachariah Whiting
- Department of Orthopaedic Surgery, George Washington University, Washington, DC
| | - Savyasachi C Thakkar
- Adult Reconstruction Division, Department of Orthopaedic Surgery, Johns Hopkins University, Columbia, Maryland
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15
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Quan T, Wang KY, Gu A, Gioia C, Malahias MA, Stoll WT, Thakkar SC, Campbell JC. Conversion total knee arthroplasty: A case complexity between primary and revision total knee arthroplasty. Knee 2021; 31:180-187. [PMID: 34256348 DOI: 10.1016/j.knee.2021.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/13/2021] [Accepted: 06/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Conversion total knee arthroplasty (TKA) may represent a more complex procedure compared with primary TKA. The purpose of this study was to compare 30-day complications between conversion TKA and primary, non-conversion TKA as well as between conversion TKA and revision TKA on a national scale using a multi-center surgical registry. METHODS Adult patients undergoing conversion TKA from 2006 to 2018 were identified in the National Surgical Quality Improvement Program database and were compared with patients who underwent primary TKA and aseptic revision TKA. In this analysis, 30-day complications were assessed. Bivariate analyses, including chi-squared and analysis of variance, and multivariate logistic regressions were performed. RESULTS Of 299,065 total patients undergoing knee arthroplasty, 1,310 (0.4%) underwent conversion TKA, 275,470 (92.1%) underwent primary TKA, and 22,285 (7.5%) underwent revision TKA. Following adjustment, patients who underwent conversion TKA were more likely to have increased risks of any complications (P < 0.001), mortality (P = 0.021), wound complications (P < 0.001), cardiac issues (P = 0.018), bleeding requiring transfusion (P < 0.001), and reoperation (P = 0.002) relative to primary TKA patients. Compared with patients who underwent revision TKA, conversion TKA patients were less likely to have septic complications (P = 0.009). CONCLUSION Conversion TKA is associated with significantly higher rates of complications compared with primary, non-conversion TKA, but less risk of sepsis compared with revision TKA. Because current reimbursement classifications do not account for the case complexity of a conversion TKA, new classifications should be implemented with reimbursements for conversion TKA approximating reimbursements for revision TKA.
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Affiliation(s)
- Theodore Quan
- Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA
| | - Kevin Y Wang
- Johns Hopkins Department of Orthopaedic Surgery, Adult Reconstruction Division, Columbia, MD, USA
| | - Alex Gu
- Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA.
| | - Casey Gioia
- Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA
| | - Michael-Alexander Malahias
- Adult Reconstruction and Joint Replacement Division, Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - William T Stoll
- Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA
| | - Savyasachi C Thakkar
- Johns Hopkins Department of Orthopaedic Surgery, Adult Reconstruction Division, Columbia, MD, USA
| | - Joshua C Campbell
- Department of Orthopedic Surgery, George Washington Hospital, Washington, DC, USA
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16
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You D, Qin L, Li K, Li D, Zhao G, Li L. A meta-analysis on advantages of peripheral nerve block post-total knee arthroplasty. Korean J Pain 2021; 34:271-287. [PMID: 34193634 PMCID: PMC8255149 DOI: 10.3344/kjp.2021.34.3.271] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 11/05/2022] Open
Abstract
Background Postoperative pain management is crucial for patients undergoing total knee arthroplasty (TKA). There have been many recent clinical trials on post-TKA peripheral nerve block; however, they have reported inconsistent findings. In this meta-analysis, we aimed to comprehensively analyze studies on post-TKA analgesia to provide evidence-based clinical suggestions. Methods We performed a computer-based query of PubMed, Embase, the Cochrane Library, and the Web of Science to retrieve related articles using neurothe following search terms: nerve block, nerve blockade, chemodenervation, chemical neurolysis, peridural block, epidural anesthesia, extradural anesthesia, total knee arthroplasty, total knee replacement, partial knee replacement, and others. After quality evaluation and data extraction, we analyzed the complications, visual analogue scale (VAS) score, patient satisfaction, perioperative opioid dosage, and rehabilitation indices. Evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation approach. Results We included 16 randomized controlled trials involving 981 patients (511 receiving peripheral nerve block and 470 receiving epidural block) in the final analysis. Compared with an epidural block, a peripheral nerve block significantly reduced complications. There were no significant between-group differences in the postoperative VAS score, patient satisfaction, perioperative opioid dosage, and rehabilitation indices. Conclusions Our findings demonstrate that the peripheral nerve block is superior to the epidural block in reducing complications without compromising the analgesic effect and patient satisfaction. Therefore, a peripheral nerve block is a safe and effective postoperative analgesic method with encouraging clinical prospects.
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Affiliation(s)
- Di You
- China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Lu Qin
- Center for Applied Statistical Research and College of Mathematics, Jilin University, Changchun, Jinlin, China
| | - Kai Li
- China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Di Li
- China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Guoqing Zhao
- China-Japan Union Hospital of Jilin University, Changchun, Jilin, China.,Jilin University, Changchun, China
| | - Longyun Li
- China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
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Gould D, Dowsey MM, Spelman T, Jo O, Kabir W, Trieu J, Bailey J, Bunzli S, Choong P. Patient-Related Risk Factors for Unplanned 30-Day Hospital Readmission Following Primary and Revision Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:E134. [PMID: 33401763 PMCID: PMC7795505 DOI: 10.3390/jcm10010134] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 01/10/2023] Open
Abstract
Total knee arthroplasty (TKA) is a highly effective procedure for advanced osteoarthritis of the knee. Thirty-day hospital readmission is an adverse outcome related to complications, which can be mitigated by identifying associated risk factors. We aimed to identify patient-related characteristics associated with unplanned 30-day readmission following TKA, and to determine the effect size of the association between these risk factors and unplanned 30-day readmission. We searched MEDLINE and EMBASE from inception to 8 September 2020 for English language articles. Reference lists of included articles were searched for additional literature. Patients of interest were TKA recipients (primary and revision) compared for 30-day readmission to any institution, due to any cause, based on patient risk factors; case series were excluded. Two reviewers independently extracted data and carried out critical appraisal. In-hospital complications during the index admission were the strongest risk factors for 30-day readmission in both primary and revision TKA patients, suggesting discharge planning to include closer post-discharge monitoring to prevent avoidable readmission may be warranted. Further research could determine whether closer monitoring post-discharge would prevent unplanned but avoidable readmissions. Increased comorbidity burden correlated with increased risk, as did specific comorbidities. Body mass index was not strongly correlated with readmission risk. Demographic risk factors included low socioeconomic status, but the impact of age on readmission risk was less clear. These risk factors can also be included in predictive models for 30-day readmission in TKA patients to identify high-risk patients as part of risk reduction programs.
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Affiliation(s)
- Daniel Gould
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Michelle M Dowsey
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
- Department of Othopaedics, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia
| | - Tim Spelman
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Olivia Jo
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Wassif Kabir
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Jason Trieu
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - James Bailey
- School of Computing and Information Systems, University of Melbourne, 3052 Melbourne, Australia;
| | - Samantha Bunzli
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Peter Choong
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
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Conversion Total Knee Arthroplasty: Prior Fracture or Osteotomy Around the Knee Leads to Increased Resource Utilization. J Arthroplasty 2020; 35:3563-3568. [PMID: 32665156 DOI: 10.1016/j.arth.2020.06.050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Prior knee surgery before total knee arthroplasty (TKA) puts patients at higher risk of inferior outcomes and increased care cost. This study compares intraoperative and postoperative variables including procedure duration, components, length of stay, readmission, complications, and reoperations among patients undergoing conversion TKA. METHODS Primary TKA from a single-surgeon database identified 130 patients with prior knee surgery to form a "conversion" cohort. One-to-one matching identified 130 patients of similar age, American Society of Anesthesiologists score, body mass index, and gender without prior knee surgery for comparison. Perioperative and 90-day postoperative variables were compared between patients with and without prior surgery, within the conversion group based on the type of prior surgery, and whether the prior surgery was bony or soft tissue. RESULTS The conversion group had longer mean operative time (96.1 vs 90.0 minutes, P = .01), higher revision component utilization (8.5% vs 0.8%, P = .005), and higher calculated blood loss (1440 vs 1249 mL, P = .004). Thirty-eight patients with prior fracture or osteotomy were compared to the remaining 92 patients in the conversion group and showed longer operative time (107.1 vs 91.3 minutes, P < .001), higher 90-day readmissions (18.4% vs 3.3%, P = .003), more complications (23.7% vs 8.7%, P = .021), and greater utilization of revision components (26.3% vs 1.1%, P < .001). CONCLUSION Patients undergoing conversion TKA required increased resource utilization, particularly patients with a prior osteotomy or fracture. Policymakers should consider these variables, as they did in conversion THA, in adding a code to account for increased case complexity and resource utilization.
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Chen J, Zhou C, Ma C, Sun G, Yuan L, Hei Z, Guo C, Yao W. Which is the best analgesia treatment for total knee arthroplasty: Adductor canal block, periarticular infiltration, or liposomal bupivacaine? A network meta-analysis. J Clin Anesth 2020; 68:110098. [PMID: 33129063 DOI: 10.1016/j.jclinane.2020.110098] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/21/2020] [Accepted: 10/10/2020] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE To review all randomized controlled trials (RCTs) comparing the analgesic efficacy of adductor canal block (ACB), periarticular infiltration (PAI), and any other mode of these treatments in analgesia, such as PAI with liposomal bupivacaine (LB), continuous adductor canal block (cACB) or ACB + PAI, after total knee arthroplasty (TKA). DESIGN Systematic review and network meta-analysis of RCTs. PATIENTS We searched PubMed, Embase, and the Cochrane database to detect all relevant RCTs on investigating the analgesic effects of ACB, PAI and LB for TKA published until April 2020. INTERVENTIONS Use of different analgesic methods of ACB, PAI, cACB, ACB + PAI and LB. MEASUREMENTS The primary endpoint was visual analog scale (VAS) score at rest and movement. The secondary endpoints were opioids consumption, length of hospitalization and knee range of motion (ROM). We used Cochrane risk of bias to assess the quality of evidence for outcomes. RESULTS Forty-two studies involving 3785 patients with 5 different methods containing ACB, PAI, ACB + PAI, continuous ACB (cACB), LB, were evaluated. According to surface under the cumulative ranking curve value, 24 h resting VAS score was the lowest the ACB + PAI (88.4%), followed by cACB (73.4%); Resting VAS score at 48 h and movement VAS score at 24 h and 48 h was the lowest in the cACB (99.9%, 92% and 100%). Total opioids consumption was the least in LB (81.4%) before cACB (60.8%). ROM was the largest in the ACB + PAI (84.1%) before cACB (78.8%). CONCLUSION Although all analgesic methods available were not evaluated, and further studies are needed to establish our results, the 24 h resting VAS score was lowest in ACB + PAI and 48 h resting and movement VAS score was lowest in cACB. CLINICAL TRIAL REGISTRATION PROSPERO (CRD 42020168102).
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Affiliation(s)
- Junheng Chen
- Department of Anesthesiology, Shantou Central Hospital, Shantou, China
| | - Chunbin Zhou
- Department of Orthopedic, First Affiliated Hospital of Shantou University, Guangdong Province, People's Republic of China
| | - Chuzhou Ma
- Department of Anesthesiology, Shantou Central Hospital, Shantou, China
| | - Guoliang Sun
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, People's Republic of China
| | - Lianxiong Yuan
- Department of Research Service Office, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, People's Republic of China
| | - Ziqing Hei
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, People's Republic of China
| | - Chunming Guo
- Department of Anesthesiology, Shantou Central Hospital, Shantou, China.
| | - Weifeng Yao
- Department of Anesthesiology, Third Affiliated Hospital of Sun Yat-sen University, Guangdong Province, People's Republic of China.
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Abstract
BACKGROUND Knee fractures may lead to post-traumatic knee osteoarthritis and subsequent TKA in some patients. However, absolute risk estimates and risk factors for TKA in patients with knee fractures compared with those of the general population remain largely unknown. Such knowledge would help establish the treatment burden and direct patient counseling after a knee fracture is sustained. QUESTIONS/PURPOSES (1) What is the short-term risk of TKA after knee fracture? (2) What is the long-term risk of TKA after knee fracture? (3) What are the risk factors for TKA in patients with knee fractures? METHODS A nationwide 20-year, matched-case comparison cohort study of prospectively collected data from the Danish National Patient Registry included all patients at least 15 years old with International Classification of Diseases, 10th revision codes DS724, DS820, or DS821 (knee fractures) on the date their knee fracture was registered. Each patient with a knee fracture was matched (by sex and age) to five people without knee fractures from the general Danish population on the date the knee fracture patient's knee fracture was registered (population controls). Patients with knee fractures and people in the population control group were followed from the date the knee fracture patient's knee fracture was registered to the date of TKA, amputation, knee fusion, emigration, death, or end of follow-up in April 2018. TKA risks for patients with knee fractures versus those for population controls and TKA risk factors in patients with knee fractures were estimated using hazard ratios (HRs) with 95% CIs. A total of 48,791 patients with knee fractures (median age 58 years [interquartile range 41-73]; 58% were female) were matched to 263,593 people in the population control group. RESULTS The HR for TKA in patients with knee fractures compared with population controls was 3.74 (95% CI 3.44 to 4.07; p < 0.01) in the first 3 years after knee fracture. Among knee fracture patients, the risk of undergoing TKA was 2% (967 of 48,791) compared with 0.5% (1280 of 263,593) of people in the population control group. After the first 3 years, the HR was 1.59 (95% CI 1.46 to 1.71) and the number of patients with knee fractures with TKA events divided by the number at risk was 2% (849 of 36,272), compared with 1% (2395 of 180,418) of population controls. During the 20-year study period, 4% of patients with knee fractures underwent TKA compared with 1% of population controls. Risk factors for TKA in patients with knee fractures were: primary knee osteoarthritis (OA) versus no primary knee OA (HR 9.57 [95% CI 5.39 to 16.98]), surgical treatment with external fixation versus open reduction and internal fixation and reduction only (HR 1.92 [95 % CI 1.01 to 3.66]), proximal tibia fracture versus patellar fracture (HR 1.75 [95 % CI 1.30 to 2.36]), and distal femur fracture versus patellar fracture (HR 1.68 [95 % CI 1.08 to 2.64]). Surgical treatment of knee fractures was also a risk factor for TKA. The HRs for TKA in patients with knee fractures who were surgically treated versus those who were treated non-surgically were 2.05 (95% CI 1.83 to 2.30) in the first 5 years after knee fracture and 1.19 (95% CI 1.01 to 1.41) after 5 years. CONCLUSIONS Patients with knee fractures have a 3.7 times greater risk of TKA in the first 3 years after knee fracture, and the risk remains 1.6 times greater after 3 years and throughout their lifetimes. Primary knee OA, surgical treatment of knee fractures, external fixation, proximal tibia fractures, and distal femur fractures are TKA risk factors. These risk estimates and risk factors highlight the treatment burden of knee fractures, building a foundation for future studies to further counsel patients on their risk of undergoing TKA based on patient-, fracture-, and treatment-specific factors. LEVEL OF EVIDENCE Level III, prognostic study.
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21
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Liu Y, Zhao XD, Zou C. Lingering risk: A meta-analysis of outcomes following primary total knee arthroplasty for patients with post-traumatic arthritis. Int J Surg 2020; 77:163-172. [PMID: 32247846 DOI: 10.1016/j.ijsu.2020.03.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 03/18/2020] [Accepted: 03/22/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Currently, no meta-analysis exists to elucidate the outcomes of primary total knee arthroplasty (TKA) in patients with post-traumatic arthritis (PTA). The primary aim of this meta-analysis was to compare revision and complication rates for patients with PTA versus osteoarthritis (OA). METHODS The following databases were used for searching existing literature (from their inception to October 2019): PubMed, Scopus, EMBASE, Cochrane Library, and Web of Science. The primary outcomes were the incidences of revision and complications, Secondary outcomes included operative time and patient-reported outcomes (PRO) scores. RESULTS Nine studies with a total of 6,783,990 patients were included. This study found that there was a statistically significant difference in the rates of superficial wound infection, periprosthetic infection, stiffness, wound complications, and revision, with these outcomes occurring more frequently in patients with PTA. However, PTA did not increase the risks for periprosthetic fracture, aseptic loosening or instability, and VTE. Moreover, PTA was associated with increased operative time, worse postoperative PRO scores, and similar changes in PRO scores. CONCLUSIONS This meta-analysis highlight the complexity of PTA and demonstrates increased risks of infection, wound complications, stiffness, and revision. Surgeons can use this information to help aid in counseling patients preoperatively.
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Affiliation(s)
- Yang Liu
- Department of Orthopedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Wai Nan Guo Xue Lane No. 37, Wuhou District, Chengdu, Sichuan Province, 610041, PR China.
| | - Xiao-Dan Zhao
- Department of Orthopedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Wai Nan Guo Xue Lane No. 37, Wuhou District, Chengdu, Sichuan Province, 610041, PR China.
| | - Chang Zou
- Department of Orthopedic Surgery, National Clinical Research Center for Geriatrics, West China Hospital of Sichuan University, Wai Nan Guo Xue Lane No. 37, Wuhou District, Chengdu, Sichuan Province, 610041, PR China
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Gould D, Dowsey M, Jo I, Choong P. Patient-related risk factors for unplanned 30-day readmission following total knee arthroplasty: a narrative literature review. ANZ J Surg 2020; 90:1253-1258. [PMID: 31970878 DOI: 10.1111/ans.15695] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 12/20/2019] [Accepted: 01/02/2020] [Indexed: 12/19/2022]
Abstract
Osteoarthritis is a debilitating condition as well as a growing global health problem, and total knee arthroplasty (TKA) is an effective treatment for advanced disease. Unplanned 30-day hospital readmission is an indicator of complications, which is a significant financial burden on healthcare systems. We reviewed the literature to better understand the patient-related factors associated with unplanned 30-day readmission following TKA. MEDLINE and EMBASE were searched for studies reporting on patient-related risk factors for unplanned 30-day readmission following primary or revision TKA for any indication. The impact of specific medical comorbidities on increasing the risk of 30-day readmission following TKA is quite well established. The following comorbidities are strongly associated with readmission: bleeding disorder, diabetes, chronic kidney disease and dialysis, chronic immunosuppressant use and history of cancer. Other significant comorbidities include: dementia; depression; haematological (coagulopathy and anaemia), cardiovascular (atrial fibrillation, cardiovascular disease, coronary artery disease and congestive heart failure), respiratory (chronic obstructive pulmonary disease) and liver diseases; and cerebrovascular accident/transient ischaemic attack (but only in revision TKA patients). The influence of variation in sex, age and body mass index each demonstrate a more complex pattern. A systematic review and meta-analysis is required to quantify the impact of the various patient-related factors on 30-day readmission following TKA. Clinicians can use this information in preoperative decision-making.
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Affiliation(s)
- Daniel Gould
- Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Michelle Dowsey
- Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Othopaedics, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Imkyeong Jo
- Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter Choong
- Department of Surgery, St Vincent's Hospital, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Othopaedics, St Vincent's Hospital, Melbourne, Victoria, Australia
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Yayac MF, Harrer SL, Deirmengian GK, Parvizi J, Courtney PM. Conversion Total Knee Arthroplasty is Associated with Increased Post-Acute Care Costs. J Arthroplasty 2019; 34:2855-2860. [PMID: 31337552 DOI: 10.1016/j.arth.2019.06.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/07/2019] [Accepted: 06/27/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Alternative payment models have been viewed as successfully decreasing costs following primary total knee arthroplasty (TKA) while maintaining quality. Concerns exist regarding access to care for patients who may utilize more resources in a bundled payment arrangement. The purpose of this study is to determine if patients undergoing conversion of prior surgery to TKA have increased costs compared to primary TKA patients. METHODS Claims from Medicare and a single private insurer were queried for all primary TKA patients at our institution from 2015 to 2016. Ninety-day post-acute care costs were compared between primary and conversion TKA. Secondary endpoints included discharge disposition, complications, and readmissions. A multivariate regression analysis was performed to identify independent risk factors for increased post-acute care costs and short-term outcome metrics. RESULTS Of 3999 primary TKA procedures, 948 patients (23%) underwent conversion TKA. Conversion TKA was associated with greater post-acute care costs in patients with commercial insurance ($4714 vs $3759, P = .034). Among Medicare beneficiaries, prior ligament reconstruction was associated with increased post-acute care costs ($1917 increase, P = .036), while prior fracture fixation approached statistical significance ($2402 increase, P = .055). Conversion TKA was an independent risk factor for readmissions (odds ratio 1.46, 95% confidence interval 1.00-2.17, P = .050), while patients with a prior open knee procedure had higher rates of complications (odds ratio 2.41, 95% confidence interval 1.004-5.778, P = .049). CONCLUSION Our data suggest that conversion from prior knee surgery to TKA is associated with increased 90-day post-acute care costs and resource utilization, particularly prior open procedures. Without appropriate risk adjustment in alternative payment models, surgeons may be financially deterred from providing quality arthroplasty care given the reduced net payment and surgical complexity of such cases.
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Affiliation(s)
- Michael F Yayac
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samantha L Harrer
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Gregory K Deirmengian
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Luthringer TA, Kester BS, Kolade O, Virk MS, Alaia MJ, Campbell KA. Shoulder Arthroplasty for Posttraumatic Arthritis Is Associated With Increased Transfusions and Longer Operative Times. J Shoulder Elb Arthroplast 2019. [DOI: 10.1177/2471549219882133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Posttraumatic arthritis (PTA) is a common sequela of proximal humerus fractures that is commonly managed with anatomic or reverse total shoulder arthroplasty (TSA). TSA for PTA is more challenging than that performed for primary osteoarthritis and frequently leads to worse patient outcomes. CPT uniformly classifies all cases of primary TSA, irrespective of procedural complexity and resource utilization. This study analyzes intraoperative differences and 30-day outcomes for anatomic and reverse TSA performed in the posttraumatic shoulder. Methods: Patients undergoing TSA from 2008 to 2015 were selected from the National Surgical Quality Improvement Program database and stratified according to concurrent procedures and administrative codes indicating posttraumatic diagnoses. Perioperative parameters and 30-day complications were recorded; multivariate analyses were performed to determine whether PTA was a risk factor for poor outcomes. Results: A total of 8508 primary and 243 posttraumatic TSAs were identified. Posttraumatic TSA patients were slightly younger ( P = .003), more likely to be female ( P < .001), smokers ( P = .029), and diabetic ( P = .003). Diagnosis of PTA was an independent risk factor for prolonged operative times ≥160 minutes (≥1 standard deviation above the mean, P = .003; odds ratio [OR]: 1.718; 95% confidence interval [CI]: 1.204–2.449) and increased bleeding requiring transfusion ( P < .001; OR: 2.719; 95% CI: 1.607–4.600). Although posttraumatic TSA had a tendency for longer hospital admissions, 30-day readmissions were not significantly different between cohorts. Conclusions: Compared with primary osteoarthritis, a preoperative diagnosis of PTA is an independent risk factor for prolonged operative times and postoperative transfusion in anatomic or reverse TSA patients; such patients may be less than optimal candidates for same-day discharges or outpatient shoulder arthroplasty.
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Affiliation(s)
- Tyler A Luthringer
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Benjamin S Kester
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Oluwadamilola Kolade
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Mandeep S Virk
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Michael J Alaia
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
| | - Kirk A Campbell
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, New York, New York
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Yayac M, Stein J, Deirmengian GK, Parvizi J, Courtney PM. Conversion Total Knee Arthroplasty Needs Its Own Diagnosis-Related Group Code. J Arthroplasty 2019; 34:2308-2312. [PMID: 31230955 DOI: 10.1016/j.arth.2019.05.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Conversion from a prior knee procedure has been demonstrated to require greater operative times and resources, but still lacks a separate procedural or facility code from primary total knee arthroplasty (TKA). The purpose of this study is to determine differences in facility costs between patients who underwent primary TKA and those who underwent conversion TKA. METHODS We retrospectively reviewed a consecutive series of patients undergoing primary TKA at 2 hospitals from 2015 to 2017, comparing itemized facility costs between primary and conversion TKA patients. A multivariate regression analysis was performed to identify independent risk factors for increased facility costs, the need for additional implants, length of stay, and discharge disposition. RESULTS Of 2447 TKA procedures, 678 (27.7%) underwent conversion TKA, which was associated with greater implant costs ($3931.47 vs $2864.67, P = .0120) and total facility costs in a multivariate regression ($94.30 increase, P = .0316). When controlling for confounding variables, patients with a prior ligament reconstruction ($402 increase, P = .0002) and prior open reduction and internal fixation ($847 increase, P = .0020) had higher costs and were more likely to require stemmed implants (P < .05). There was an increase in TKA implant cost by $538 in patients with implants from a prior procedure (P < .0001). CONCLUSION Conversion TKA is associated with greater implant and inpatient facility costs than primary TKA, particularly those who had a history of an open knee procedure. A separate diagnosis-related group should be created for conversion TKA given the increased cost and complexity of these procedures compared to primary TKA.
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Affiliation(s)
- Michael Yayac
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | - Jonah Stein
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Conversion Total Knee Arthroplasty: A Distinct Surgical Procedure With Increased Resource Utilization. J Arthroplasty 2019; 34:S114-S120. [PMID: 30824294 DOI: 10.1016/j.arth.2019.01.070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/24/2019] [Accepted: 01/29/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Current Procedural Terminology coding currently makes no distinction between primary total knee arthroplasty (TKA) and conversion TKA, in which periarticular hardware components must be removed prior to or during TKA. We hypothesize that conversion TKA will carry increased operative time, blood loss, postoperative complications, and 90-day emergency department/readmission rate compared to primary TKA. METHODS Patients undergoing conversion TKA from 2005 to 2017 were identified from an institutional database and matched to primary TKA patients by age, gender, American Society of Anesthesiologists score, body mass index, and procedure date (±1 year). Intraoperative data and 90-day postoperative complications were compared between groups. RESULTS One hundred nine conversion TKA patients with periarticular hardware were removed prior to (n = 51) or during (n = 58) TKA and 109 primary TKA control patients were included. Conversion TKA was associated with increased tourniquet time (91 vs 71 minutes, P < .001), operative time (147 vs 113 minutes, P < .001), blood loss (225 vs 176 mL, P = .010), 90-day readmissions (14.6% vs 4.2%, P = .020), wound complication (5.6% vs 0.0%, P = .025), periprosthetic joint infection (7.9% vs 0.0%, P = .005), irrigation/debridement (9.0% vs 1.1%, P = .016), and a trend toward increased mechanical complication (6.7% vs 1.1%, P = .058). Timing of hardware removal did not affect intraoperative or postoperative outcomes. CONCLUSION Conversion TKA is associated with higher operative time, blood loss, readmission rate, and postoperative complications compared to primary TKA. Without a proper billing code and appropriate reimbursement level to match the expected operative and postacute resource utilization by these cases, physicians may be disincentivized to perform these operations.
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27
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Kornah BA, Safwat HM, Abdel-Hameed SK, Abdel-AAl M, Abdelaziz M, Abuelesoud MI, Saleem N. Managing of post-traumatic knee arthritis by total knee arthroplasty: case series of 15 patients and literature review. J Orthop Surg Res 2019; 14:168. [PMID: 31151399 PMCID: PMC6543569 DOI: 10.1186/s13018-019-1180-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 04/30/2019] [Indexed: 01/18/2023] Open
Abstract
Purpose Post-traumatic arthritis is one of the leading causes of joint disability. This study aims at outlining outcomes of total knee arthroplasty in post-traumatic arthritis and technical difficulty and reviewing literature regarding this issue Patients and methods We analyzed the outcome of total knee arthroplasty following post-traumatic arthritis in 15 patients with unilateral involvement. Ten had stable arthritic knees treated with posterior stabilized (PS) prosthesis, while five with unstable arthritic knees treated as follows: three with ligamentous instability managed by constrained condylar prosthesis and two with osseous deficiency, metal augmentation used together with stemmed constrained condylar prosthesis (CCK). Average follow-up 6 years, mean age 49.8 years at time of arthroplasty. Patient outcomes were evaluated on the basis of Knee Society score. Results Mean clinical knee society scores (CKSS) at latest follow-up improved from 43.6 ± 11.66 points to 77.3± points postoperatively while mean functional knee society score (FKSS) improved from 40. ± 6.3 to 76.6 ± 84 postoperatively. Patients with stable knees had a higher mean values, both clinical and functional KSS, while unstable knees were poorer. Complications occurred in three cases, one with wound dehiscence with prolonged drainage treated by antibiotics and daily dressings until the wound closed completely, one was complicated by infection and improved by serial debridement, and the third case had aseptic loosening which required revision surgery. Conclusion Total knee arthroplasty for post-traumatic arthritis decreases pain and improves knee function. However; the procedure is not as simple as primary arthroplasty as it is technically demanding and requires adequate planning.
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Affiliation(s)
| | | | | | - Mohamed Abdel-AAl
- Ministry of Health, Manshiet el Bakry Hospital, 61 Taha Heussein Street, Nozha, Heliopolis, Cairo, Egypt.
| | | | | | - Nagy Saleem
- Faculty of Medicine for Boys, Al-Azhar University, Cairo, Egypt
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Zuo W, Guo W, Ma J, Cui W. Dose adductor canal block combined with local infiltration analgesia has a synergistic effect than adductor canal block alone in total knee arthroplasty: a meta-analysis and systematic review. J Orthop Surg Res 2019; 14:101. [PMID: 30971284 PMCID: PMC6458644 DOI: 10.1186/s13018-019-1138-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 03/27/2019] [Indexed: 11/10/2022] Open
Abstract
Background Both adductor canal block (ACB) and local infiltration analgesia (LIA) are effective procedures for postoperative pain control in total knee arthroplasty (TKA) without motor blockade. However, whether ACB combined with LIA has synergistic effect than ACB alone remains unknown. We hypothesized that ACB combined with LIA would have better postoperative pain control, less rescue opioid consumption and faster rehabilitation than ACB alone, without higher adverse event rate. Methods We conducted a meta-analysis to identify relevant articles involving ACB + LIA and ACB alone in patients who underwent TKA from online register databases such as PubMed, Medline, Embase, Web of Science, and the Cochrane Library. The primary outcomes were visual analog scale (VAS) score and morphine consumption. Secondary outcomes were postoperative range of motion (ROM) and adverse event rate. Results According to the keyword search from online register databases, a total of 879 articles were identified, of which six articles that met the inclusion criteria were determined as eligible. There were three randomized controlled trials (RCTs) and three non-randomized prospective studies. As compared to the ACB alone group, the ACB + LIA group had lower VAS at rest on postoperative day 0 and 1, as well as significantly less morphine consumption on postoperative day 0 and 1 and significantly better postoperative ROM. There were no significant differences in adverse event rate. Conclusion As compared to ACB alone, ACB + LIA provides better analgesia and faster functional rehabilitation in patients who underwent TKA.
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Affiliation(s)
- Wei Zuo
- Peking University China-Japan Friendship School of Clinical Medicine, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Wanshou Guo
- Center for Osteonecrosis and Joint Preserving & Reconstruction, Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China.
| | - Jinhui Ma
- Center for Osteonecrosis and Joint Preserving & Reconstruction, Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
| | - Wei Cui
- Center for Osteonecrosis and Joint Preserving & Reconstruction, Department of Orthopaedic Surgery, China-Japan Friendship Hospital, 2 Yinghuadong Road, Chaoyang District, Beijing, 100029, China
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He QF, Wang HX, Sun H, Zhan Y, Zhang BB, Xie XT, Luo CF. Medial Open-wedge Osteotomy with Double-plate Fixation for Varus Malunion of the Distal Femur. Orthop Surg 2019; 11:82-90. [PMID: 30724021 PMCID: PMC6430482 DOI: 10.1111/os.12421] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 11/29/2018] [Accepted: 12/13/2018] [Indexed: 11/30/2022] Open
Abstract
Objective To present our clinical experience of treating varus malunion of the distal femur through a medial open‐wedge osteotomy with double‐plate fixation. Methods A prospective cohort study was performed. From January 2005 to February 2015, 15 consecutive patients with varus malunion following distal femur fractures were surgically treated at a single level I trauma center. The coronal and sagittal deformity were corrected by a medial open‐wedge osteotomy of the distal femur. A medial buttress plate was used to maintain the realignment. A lateral locking plate was additionally used as a protection plate. The mean age of patients at the time of the surgery was 35.5 years (range, 22–58 years). The radiographical evaluation included the mechanical femorotibial angle, the mechanical lateral distal femoral angle, the anatomic posterior distal femoral angle, and the leg length discrepancy. Clinical outcome evaluation consisted of the range of motion (ROM) and Hospital for Special Surgery (HSS) score. Results Mean follow‐up was 7.4 years (range, 4–11.5 years). Varus and flexion malalignment and limb discrepancy were adequately corrected in all patients. The mechanical femorotibial angle, the mechanical lateral distal femoral angle, and the anatomic posterior distal femoral angle were restored from 17.5° (range, 13°–25°) to 2.3° (range, − 2°–7°), 102.3° (range, 95°–112°) to 85.2° (range, 81°–92°), and 77.1° (range, 65°–87°) to 82.7° (range, 76°–88°), respectively. The leg length discrepancy was diminished from 3.4 cm (range, 2.4–4.5 cm) to 0.8 cm (range, 0–1.7 cm). The average bone healing time was 4.1 months (range, 2.5–6 months). The average ROM of the affected knees at 24‐month follow‐up was 3.4°–112.55°. The score of HSS at 4‐years follow‐up was 76.1 (range, 64–88). No internal fixation failure or secondary operation was noted until the last follow‐up. Conclusion Medial open‐wedge osteotomy can adequately correct the posttraumatic varus malunion of the distal femur. With fixation of the double plate, non‐displaced bone healing and good functional outcome are expected.
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Affiliation(s)
- Qi-Fang He
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Han-Xu Wang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hui Sun
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yu Zhan
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Bin-Bin Zhang
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xue-Tao Xie
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Cong-Feng Luo
- Department of Orthopaedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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30
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Neuprez A, Neuprez AH, Kaux JF, Kurth W, Daniel C, Thirion T, Huskin JP, Gillet P, Bruyère O, Reginster JY. Early Clinically Relevant Improvement in Quality of Life and Clinical Outcomes 1 Year Postsurgery in Patients with Knee and Hip Joint Arthroplasties. Cartilage 2018; 9:127-139. [PMID: 29262700 PMCID: PMC5871126 DOI: 10.1177/1947603517743000] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective To measure and identify the determinants of the outcomes after hip/knee arthroplasty (HA/KA) in patients with osteoarthritis during the first postsurgical year. Design In this prospective observational study, we evaluated the preoperative and postoperative (3, 6, and 12 months) outcomes of 626 patients who underwent HA (346 with median age 65 years, 59% female) or KA (280 with median age 66.5 years, 54% female) between 2008 and 2013. Generic and specific tools were used to measure health-related quality of life (HRQoL) and utility. Good outcome was defined as an improvement in WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index) greater than or equal to the minimal important difference (MID). Regressions were performed to evaluate the relationship between preoperative and postoperative measures and evolution of WOMAC/good outcome. Results We observed an almost systematic improvement of all parameters for up to 12 months, but especially at the 3-month follow-up. The low number of comorbidities and the absence of postoperative complications were the common determinants of improvement of WOMAC total score after 12 months. Other parameters (background of the joint, preoperative function and length of hospital stay in KA group; place of discharge in HA group) affected the evolution of WOMAC scores. 87.09% of HA and 73.06% of KA patients experienced a good outcome. A small number of comorbidities, a worse preoperative function, a shortened hospital stay (KA only), and an absence of early postoperative complications (HA only) significantly predicted a good outcome. Conclusions Intermediate HRQoL following HA or KA improved quickly from preoperative levels for all instruments. More than 70% of patients achieved a good outcome defined as improved pain, stiffness and disability and the predictors are slightly close.
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MESH Headings
- Aged
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/psychology
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/psychology
- Female
- Follow-Up Studies
- Hip Joint/pathology
- Humans
- Knee Joint/pathology
- Length of Stay/statistics & numerical data
- Male
- Middle Aged
- Osteoarthritis, Hip/pathology
- Osteoarthritis, Hip/surgery
- Osteoarthritis, Knee/pathology
- Osteoarthritis, Knee/surgery
- Postoperative Period
- Preoperative Care
- Prospective Studies
- Quality of Life/psychology
- Treatment Outcome
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Affiliation(s)
- Audrey Neuprez
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liege, Belgium
- Rehabilitation and Sports Traumatology Department, University Hospital of Liège, Liege, Belgium
| | - Arnaud H. Neuprez
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liege, Belgium
| | - Jean-François Kaux
- Rehabilitation and Sports Traumatology Department, University Hospital of Liège, Liege, Belgium
| | - William Kurth
- Orthopaedic Surgery Department, University Hospital of Liège, Liege, Belgium
| | - Christophe Daniel
- Orthopaedic Surgery Department, University Hospital of Liège, Liege, Belgium
| | - Thierry Thirion
- Orthopaedic Surgery Department, University Hospital of Liège, Liege, Belgium
| | - Jean-Pierre Huskin
- Orthopaedic Surgery Department, University Hospital of Liège, Liege, Belgium
| | - Philippe Gillet
- Orthopaedic Surgery Department, University Hospital of Liège, Liege, Belgium
| | - Olivier Bruyère
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liege, Belgium
| | - Jean-Yves Reginster
- Department of Public Health, Epidemiology and Health Economics, University of Liège, Liege, Belgium
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Aurich M, Koenig V, Hofmann G. Comminuted intraarticular fractures of the tibial plateau lead to posttraumatic osteoarthritis of the knee: Current treatment review. Asian J Surg 2018; 41:99-105. [DOI: 10.1016/j.asjsur.2016.11.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 11/18/2016] [Accepted: 11/24/2016] [Indexed: 11/30/2022] Open
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Ge DH, Anoushiravani AA, Kester BS, Vigdorchik JM, Schwarzkopf R. Preoperative Diagnosis Can Predict Conversion Total Knee Arthroplasty Outcomes. J Arthroplasty 2018; 33:124-129.e1. [PMID: 28939032 DOI: 10.1016/j.arth.2017.08.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 07/27/2017] [Accepted: 08/14/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Compared to total knee arthroplasty (TKA) for primary osteoarthritis, conversion TKAs in the post-traumatic setting are associated with increased operative times, infection rates, and readmissions. We aim at determining how post-traumatic osteoarthritis and previous knee surgery influence postoperative outcomes in conversion TKA. METHODS Seventy-two conversion TKA procedures with prior knee trauma at a single institution between April 2012 and 2016 were examined. Twenty-seven (37.5%) cases had a preoperative site-specific diagnosis such as fracture of the proximal tibia, distal femur, or patella whereas 45 (62.5%) cases had a preoperative diagnosis of significant soft-tissue trauma. These 2 groups were compared in terms of total implant cost, length of stay, complications, and readmission and reoperation rates. A subanalysis was conducted to evaluate the effects of previous knee surgery on surgical outcomes. RESULTS The postfracture TKA cohort suffered significantly higher early surgical site complications (22% vs 4.4%, P = .02) and 90-day readmissions (14.8% vs 2.2%, P = .042) compared to the soft-tissue trauma cohort. Operative time, total implant costs, length of stay, medical complications, 30-day readmissions, and 90-day reoperation rates did not significantly differ. It was also found that patients with multiple prior knee surgeries compared to one prior knee surgery are younger (53.0 vs 63.1, P = .003), healthier, and receive significantly more expensive implants (1.72 vs 1.07, P = .026). In addition, patients with previous open reduction internal fixations experience more surgical site complications than patients with previous arthroscopies (31% vs 3.3%, P = .042). CONCLUSION Patients with previous site-specific fracture are more likely to experience surgical site complications and 90-day readmissions after conversion TKA than patients with previous soft-tissue knee trauma. Multiple previous knee surgeries appear to serve as an independent factor in the selection of costlier implants irrespective of preoperative diagnosis.
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Affiliation(s)
- David H Ge
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
| | - Afshin A Anoushiravani
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
| | - Benjamin S Kester
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
| | - Jonathan M Vigdorchik
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, Department of Orthopaedic Surgery, NYU Langone Medical Center, Hospital for Joint Diseases, New York, NY
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Is Adductor Canal Block Better Than Femoral Nerve Block in Primary Total Knee Arthroplasty? A GRADE Analysis of the Evidence Through a Systematic Review and Meta-Analysis. J Arthroplasty 2017; 32:3238-3248.e3. [PMID: 28606458 DOI: 10.1016/j.arth.2017.05.015] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 04/26/2017] [Accepted: 05/08/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) is associated with intense postoperative pain with a need for early ambulation to gain function and prevent postoperative complications. Compared with femoral nerve block (FNB), adductor canal block (ACB) can relieve postoperative pain and preserve quadriceps muscle strength. This meta-analysis was conducted to investigate which analgesic method provides better pain relief and functional recovery after TKA. METHOD We conducted a meta-analysis to identify relevant randomized controlled trials involving ACB and FNB after TKA in electronic databases, including Web of Science, Embase, PubMed, and the Cochrane Library, up to November 2016. Finally, 9 randomized controlled trials involving 609 patients (668 knees) were included in our study. Review Manager Software and Grading of Recommendations Assessment, Development, and Evaluation profiler were used to perform the meta-analysis. RESULTS Compared with FNB, ACB resulted in better quadriceps muscle strength and mobilization ability. There were no significant differences in the visual analog scale at rest, visual analog scale with mobilization, rescue opioid consumption, patient satisfaction, and length of hospital stay. CONCLUSION Compared with FNB, ACB shows similar pain control after TKA. However, ACB can better preserve quadriceps muscle strength and improve mobilization ability. In conclusion, ACB showed better functional recovery after TKA without compromising pain control. Therefore, ACB is recommended as an alternative analgesic method for early ambulation after TKA.
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