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Premkumar A, Anatone A, Illescas A, Memtsoudis S, Cross MB, Sculco PK, Gonzalez Della Valle A. Perioperative Use of Antifibrotic Medications Associated With Lower Rate of Manipulation After Primary TKA: An Analysis of 101,366 Patients. J Arthroplasty 2022; 37:S1010-S1015.e1. [PMID: 35283229 DOI: 10.1016/j.arth.2022.03.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/28/2022] [Accepted: 03/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Several commonly prescribed medications have known antifibrotic properties and have been shown to reduce postoperative scar formation in other clinical areas, but it is unknown whether the use of such medications perioperatively in patients undergoing TKA may improve rates of postoperative stiffness. METHODS A large US employer-sponsored healthcare database (Truven Marketscan) was queried for patients who underwent elective primary TKA for primary osteoarthritis between 2015-2019. Demographic information and comorbidities were recorded, along with whether patients were prescribed one of several medications with known antifibrotic properties during the three months before or after surgery. RESULTS Complete data were available for 101,366 patients undergoing TKA, of which 4,536 underwent MUA (4.5%). Perioperative use of any antifibrotic medication was associated with a lower likelihood of undergoing MUA (P < .001). When controlling for age, sex, comorbidities, opioid use, length of stay, among other variables, perioperative use of specific ACE inhibitors (OR 0.91, CI 0.84-1, P = .042), COX-2 inhibitors (OR 0.88, CI 0.81-0.96, P = .002), and angiotensin II receptor blockers, specifically losartan (OR 0.80, CI 0.70-0.91, P = .007) all remained significantly associated with lower rates of MUA. CONCLUSION This study, spanning over a hundred thousand primary TKA procedures over a recent five-year period, demonstrates an association between perioperative use of specific medications with antifibrotic properties and a decreased rate of MUA. These data will help inform future studies aimed to prospectively evaluate the potential of antifibrotic medications in preventing postoperative stiffness in high-risk patients undergoing knee arthroplasty.
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Affiliation(s)
- Ajay Premkumar
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, NY
| | - Alex Anatone
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, NY
| | - Alex Illescas
- Hospital for Special Surgery, Biostatistics Core, New York, NY
| | - Stavros Memtsoudis
- Hospital for Special Surgery, Department of Anesthesiology, Critical Care, and Pain Management, New York, NY
| | - Michael B Cross
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, NY
| | - Peter K Sculco
- Hospital for Special Surgery, Adult Reconstruction and Joint Replacement, New York, NY
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Salamanna F, Contartese D, Brogini S, Visani A, Martikos K, Griffoni C, Ricci A, Gasbarrini A, Fini M. Key Components, Current Practice and Clinical Outcomes of ERAS Programs in Patients Undergoing Orthopedic Surgery: A Systematic Review. J Clin Med 2022; 11:4222. [PMID: 35887986 PMCID: PMC9322698 DOI: 10.3390/jcm11144222] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols have led to improvements in outcomes in several surgical fields, through multimodal optimization of patient pathways, reductions in complications, improved patient experiences and reductions in the length of stay. However, their use has not been uniformly recognized in all orthopedic fields, and there is still no consensus on the best implementation process. Here, we evaluated pre-, peri-, and post-operative key elements and clinical evidence of ERAS protocols, measurements, and associated outcomes in patients undergoing different orthopedic surgical procedures. A systematic literature search on PubMed, Scopus, and Web of Science Core Collection databases was conducted to identify clinical studies, from 2012 to 2022. Out of the 1154 studies retrieved, 174 (25 on spine surgery, 4 on thorax surgery, 2 on elbow surgery and 143 on hip and/or knee surgery) were considered eligible for this review. Results showed that ERAS protocols improve the recovery from orthopedic surgery, decreasing the length of hospital stays (LOS) and the readmission rates. Comparative studies between ERAS and non-ERAS protocols also showed improvement in patient pain scores, satisfaction, and range of motion. Although ERAS protocols in orthopedic surgery are safe and effective, future studies focusing on specific ERAS elements, in particular for elbow, thorax and spine, are mandatory to optimize the protocols.
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Affiliation(s)
- Francesca Salamanna
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Deyanira Contartese
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Silvia Brogini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Andrea Visani
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
| | - Konstantinos Martikos
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Cristiana Griffoni
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Alessandro Ricci
- Anesthesia-Resuscitation and Intensive Care, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy;
| | - Alessandro Gasbarrini
- Spine Surgery Unit, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (K.M.); (C.G.); (A.G.)
| | - Milena Fini
- Complex Structure Surgical Sciences and Technologies, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy; (F.S.); (D.C.); (A.V.); (M.F.)
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Poultsides LA, Triantafyllopoulos GK, Wanivenhaus F, Pumberger M, Memtsoudis SG, Sculco TP. Same-Day Surgery Does Not Increase the Manipulation Under Anesthesia and Reoperation Rates for Stiffness Following Bilateral Total Knee Arthroplasty. J Arthroplasty 2019; 34:2646-2651. [PMID: 31272825 DOI: 10.1016/j.arth.2019.06.017] [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: 02/05/2019] [Revised: 06/03/2019] [Accepted: 06/07/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There is a paucity of data on the incidence of stiffness and need for subsequent manipulation under anesthesia (MUA) and reoperation following same-day bilateral total knee arthroplasty (BTKA). We compared the rates of at least 1 MUA, bilateral knee involvement, single and multiple MUA rates, and stiffness-related reoperation rates between patients undergoing same-day, same-admission staged, and staged within 1 year BTKA in a tertiary institution. METHODS We analyzed institutional data for 3175 same-day (group A), 153 same-admission staged (group B), and 1226 staged within 1 year BTKA patients (group C) from 1998 to 2009. Several variables, including patient demographics, comorbidity profile, Charlson-Deyo index, and range of motion at different time points, were tabulated. Follow-up was minimum 1 year after first MUA. Univariate analyses were performed using the Wilcoxon rank-sum or Kruskal-Wallis test, and Fisher exact or the chi-square test for continuous and categorical variables, respectively. The Cochran-Armitage trend test was used to check the bilateral knee involvement rate across groups. RESULTS Overall, 2.2% (98/4554) of BTKA patients required MUA. The rate of at least 1 MUA was similar across groups but the percentage of bilateral knee involvement was higher in group A. The single MUA rate was comparable among groups. Both no revision and revision reoperation rates were similar among the manipulated groups. CONCLUSION Same-day BTKA was not associated with increased incidence of single or multiple MUA and stiffness-related reoperation rates. These findings may facilitate preoperative counseling in patients with symptomatic bilateral knee disease, eligible for same-day BTKA.
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Affiliation(s)
- Lazaros A Poultsides
- Department of Orthopaedic Surgery, NYU Langone Medical Center, NYU Langone Orthopedic Hospital, New York, NY
| | - Georgios K Triantafyllopoulos
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Florian Wanivenhaus
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Matthias Pumberger
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
| | - Thomas P Sculco
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY
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Thorsteinsson H, Hedström M, Robertsson O, Lundin N, W-Dahl A. Manipulation under anesthesia after primary knee arthroplasty in Sweden: incidence, patient characteristics and risk of revision. Acta Orthop 2019; 90:484-488. [PMID: 31269851 PMCID: PMC6746267 DOI: 10.1080/17453674.2019.1637177] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The incidence of manipulation under anesthesia (MUA) after knee arthroplasty surgery has been reported to vary between 0.5% and 10%. We evaluated the incidence of MUA after primary knee arthroplasty in Sweden, the demographics of the patients and the risk of revision. Patients and methods - Between 2009 and 2013, 64,840 primary total and unicompartmental knee arthroplasties (TKA and UKA) were registered in the Swedish Knee Arthroplasty Register (SKAR). MUAs performed between 2009 and 2014 were identified through the in- and outpatient registers of the Swedish National Board of Health and Welfare. Pertinent data were verified through medical records and patient demographics and revisions were obtained from the SKAR. Results - 1,258 MUAs were identified. Of these, 1,078 were 1st-time MUAs, performed within 1 year after the primary knee arthroplasty. The incidence of MUA was 1.7% and the incidence varied between hospitals from 0% to 5%. The majority were performed after TKA (98%), in younger patients (65% < 65 years), women (64%), and relatively healthy persons (88% had ASA ≤ 2). The cumulative risk of revision at 10 years was 10% (95% CI 8.6-12), similar for men and women. Interpretation - In Sweden, MUA is a rather uncommon measure after knee arthroplasty, especially after UKA. The CRR at 10 years was doubled compared to the general knee arthroplasty population. The frequency of the procedure varies between hospitals but in general it is performed more frequently in healthier and younger patients.
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Affiliation(s)
| | - Margareta Hedström
- Department of Orthopedics, Karolinska University Hospital, Huddinge; ,Department of Clinical Science, Intervention and Technology, Division of Orthopaedics and Biotechnology, Karolinska Institutet, Stockholm, Sweden
| | - Otto Robertsson
- Department of Orthopedics, Skane University Hospital, Lund; ,The Swedish Knee Arthroplasty Register;
| | - Natalie Lundin
- Department of Orthopedics, Karolinska University Hospital, Huddinge; ,Department of Clinical Science, Intervention and Technology, Division of Orthopaedics and Biotechnology, Karolinska Institutet, Stockholm, Sweden
| | - Annette W-Dahl
- Department of Orthopedics, Skane University Hospital, Lund; ,The Swedish Knee Arthroplasty Register;
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Zachwieja E, Perez J, Hardaker WM, Levine B, Sheth N. Manipulation Under Anesthesia and Stiffness After Total Knee Arthroplasty. JBJS Rev 2018; 6:e2. [DOI: 10.2106/jbjs.rvw.17.00113] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Pamilo KJ, Torkki P, Peltola M, Pesola M, Remes V, Paloneva J. Fast-tracking for total knee replacement reduces use of institutional care without compromising quality. Acta Orthop 2018; 89:184-189. [PMID: 29160123 PMCID: PMC5901516 DOI: 10.1080/17453674.2017.1399643] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background and purpose - Fast-tracking shortens the length of the primary treatment period (length of stay, LOS) after total knee replacement (TKR). We evaluated the influence of the fast-track concept on the length of uninterrupted institutional care (LUIC) and other outcomes after TKR. Patients and methods - 4,256 TKRs performed in 4 hospitals between 2009-2010 and 2012-2013 were identified from the Finnish Hospital Discharge Register and the Finnish Arthroplasty Register. Hospitals were classified as fast track (Hospital A) and non-fast track (Hospitals B, C and D). We analyzed length of uninterrupted institutional care (LUIC), LOS, discharge destination, readmission, revision, manipulation under anesthesia (MUA) and mortality rate in each hospital. We compared these outcomes for TKRs performed in Hospital A before and after fast-track implementation and we also compared Hospital A outcomes with the corresponding outcomes for the other 3 hospitals. Results - After fast-track implementation, median LOS in Hospital A fell from 5 to 3 days (p < 0.001) and (median) LUIC from 7 to 3 (p < 0.001) days. These reductions in LOS and LUIC were accompanied by an increase in the discharge rate to home (p = 0.01). Fast-tracking in Hospital A led to no increase in 14- and 42-day readmissions, MUA, revision or mortality compared with the rates before fast-tracking, or with those in the other hospitals. Of the 4 hospitals, LOS and LUIC were most reduced in Hospital A. Interpretation - A fast-track protocol reduces LUIC and LOS after TKR without increasing readmission, complication or revision rates.
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Affiliation(s)
- Konsta J Pamilo
- Department of Orthopaedics and Traumatology, Central Finland Hospital, Jyväskylä,Correspondence:
| | | | - Mikko Peltola
- Centre for Health and Social Economics CHESS, National Institute for Health and Welfare, Helsinki
| | - Maija Pesola
- Department of Orthopaedics and Traumatology, Central Finland Hospital, Jyväskylä
| | | | - Juha Paloneva
- Department of Orthopaedics and Traumatology, Central Finland Hospital, Jyväskylä
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Jenny JY. Minimally invasive unicompartmental knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 28:793-797. [PMID: 29280006 DOI: 10.1007/s00590-017-2107-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 12/05/2017] [Indexed: 11/26/2022]
Abstract
The exact indication for a unicompartmental knee arthroplasty (UKA) remains debated. Minimally invasive techniques have been developed to decrease the surgical trauma related to the prosthesis implantation, and this technique is well fitted to UKA. However, there are concerns about loss of accuracy with minimally invasive techniques. Furthermore, rapid recovery techniques have been developed in order to reduce the length of hospital stay. Again, UKA is well fitted to these new developments of postoperative care. We combine routinely a minimal invasive operative technique with navigation assistance to ensure proper positioning of the implants as well as an optimal ligamentous balance. Instruments have been adapted for use with a typical 6-cm skin incision with little change from the conventional navigated operating technique. A multimodal pain treatment is implemented immediately after the implantation, with special attention to a routine saphenous nerve blockade. Patients are instructed to stand up on the day of surgery with full weight bearing and to mobilize the knee joint without restriction. They may be discharged at least on the day following surgery, and the most favorable patients may be operated in our day-case surgery unit. These conclusions should be confirmed on a larger scale.
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Affiliation(s)
- Jean-Yves Jenny
- Centre de Chirurgie Orthopédique et de la Main, Hôpitaux Universitaires de Strasbourg, 10 Avenue Baumann, 67400, Illkirch-Graffenstaden, France.
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Meehan JP, Monazzam S, Miles T, Danielsen B, White RH. Postoperative Stiffness Requiring Manipulation Under Anesthesia Is Significantly Reduced After Simultaneous Versus Staged Bilateral Total Knee Arthroplasty. J Bone Joint Surg Am 2017; 99:2085-2093. [PMID: 29257014 DOI: 10.2106/jbjs.17.00130] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND For patients with symptomatic bilateral knee arthritis, it is unknown whether the risk of developing stiffness requiring manipulation under anesthesia postoperatively is higher or lower for those undergoing simultaneous bilateral total knee arthroplasty (TKA) compared with those having staged bilateral TKA. Therefore, we undertook this study to evaluate the risk of requiring manipulation under anesthesia in staged versus simultaneous bilateral TKA as well as patients undergoing unilateral TKA. METHODS We utilized the California Patient Discharge Database, which is linked with the California Emergency Department, Ambulatory Surgery, and master death file databases. Using a literature-based estimate of the number of patients who failed to undergo the second stage of a staged bilateral TKA, replacement cases were randomly selected from patients who had unilateral TKA and were matched on 8 clinical characteristics of the patients who had staged bilateral TKA. Hierarchical multivariate logistic regression was performed to determine the risk-adjusted odds of manipulation in patients undergoing unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA using yearly hospital TKA volume as a random effect. Adjustment was made to allow fair comparison of the outcome at 90 and 180 days of follow-up after staged compared with simultaneous bilateral TKA. RESULTS During the time period from 2005 through 2013, the cumulative incidence of manipulation within 90 days was 2.14% for unilateral TKA (4,398 events per 205,744 patients), 2.11% for staged bilateral TKA (724 events per 34,352 patients), and 1.62% for simultaneous bilateral TKA (195 events per 12,013 patients). At 180 days of complete follow-up, the cumulative incidence of manipulation was 3.07% after unilateral TKA (6,313 events per 205,649 patients), 2.89% after staged bilateral TKAs (957 events per 33,169 patients), and 2.29% after simultaneous bilateral TKA (267 events per 11,653 patients). With multivariate analyses used to adjust for relevant risk factors, the 90-day odds ratio (OR) of undergoing manipulation after simultaneous bilateral TKA was significantly lower than that for unilateral TKA (OR = 0.70; 95% confidence interval [CI], 0.57 to 0.86) and staged bilateral TKA (OR = 0.71; 95% CI, 0.57 to 0.90). Similarly, at 180 days, the odds of undergoing manipulation were significantly lower after simultaneous bilateral TKA than after both unilateral TKA (OR = 0.71; 95% CI, 0.59 to 0.84) and staged bilateral TKA (OR = 0.76; 95% CI, 0.63 to 0.93). The frequency of manipulation was significantly associated with younger age, fewer comorbidities, black race, and the absence of obesity. CONCLUSIONS Although the ORs were small (close to 1), simultaneous bilateral TKA had a significantly decreased rate of stiffness requiring manipulation under anesthesia at 90 days and 180 days after knee replacement compared with that after staged bilateral TKA and unilateral TKA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- John P Meehan
- Departments of Orthopaedic Surgery (J.P.M., S.M., and T.M.) and Medicine (R.H.W.), University of California, Davis, Sacramento, California
| | - Shafagh Monazzam
- Departments of Orthopaedic Surgery (J.P.M., S.M., and T.M.) and Medicine (R.H.W.), University of California, Davis, Sacramento, California
| | - Troy Miles
- Departments of Orthopaedic Surgery (J.P.M., S.M., and T.M.) and Medicine (R.H.W.), University of California, Davis, Sacramento, California
| | | | - Richard H White
- Departments of Orthopaedic Surgery (J.P.M., S.M., and T.M.) and Medicine (R.H.W.), University of California, Davis, Sacramento, California
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