Enhancing Recovery After Total Knee Arthroplasty

Does interaction occur between risk factors for revision total knee arthroplasty?

INTRODUCTION

Several risk factors for revision TKA have previously been identified, but interactions between risk factors may occur and affect risk of revision. To our knowledge, such interactions have not been previously studied. As patients often exhibit multiple risk factors for revision, knowledge of these interactions can help improve risk stratification and patient education prior to TKA.

MATERIALS AND METHODS

The State Inpatient Databases (SID), part of the Healthcare Cost and Utilization Project (HCUP), were queried to identify patients who underwent TKA between January 1, 2006 and December 31, 2015. Risk factors for revision TKA were identified, and interactions between indication for TKA and other risk factors were analyzed.

RESULTS

Of 958,944 patients who underwent TKA, 33,550 (3.5%) underwent revision. Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA were significantly associated with revision (p < 0.05). Age was the strongest predictor (p  < 0.0001), with younger patients exhibiting higher revision risk. Risks associated with age were modified by an interaction with indication for TKA (p < 0.0001). There was no significant interaction between sex and indication for TKA (p = 0.535) or race and indication for TKA (p = 0.187).

CONCLUSIONS

Age, sex, race, length of stay, Elixhauser readmission score, urban/rural designation, and indication for TKA are significantly associated with revision TKA. Interaction occurs between age and indication.

Early implementation of MAK robotic device in total knee arthroplasty rehabilitation: A proof-of-concept study

BACKGROUND

Effective rehabilitation following total knee arthroplasty (TKA) is crucial for enhancing both range of motion (ROM) and functional outcomes. While robotics has demonstrated its potential in various medical contexts, the evidence on its application in TKA rehabilitation is still scarce. The marsi active knee (MAK), a robotic device that has already proven to be safe and beneficial in people with neurological disease, has been tested to facilitate the rehabilitation of TKA patients.

OBJECTIVE

This study aims to evaluate the safety, patient satisfaction, and clinical impact of integrating the MAK into an early rehabilitation regimen for TKA patients.

METHODS

The intervention comprised 14 one-hour sessions administered thrice a week, utilizing the MAK within 48 h post-TKA surgery. The rehabilitation sessions incorporated exercises involving passive mobilizations, sit-to-stand transitions, and gait training. Comprehensive data encompassing safety parameters, patient satisfaction, and clinical outcomes were meticulously collected and analyzed.

RESULTS

Six participants successfully completed the rehabilitation protocol with the MAK device. Notably, no significant adverse events were documented. Application of the device corresponded to perceptible reductions in self-reported pain levels. Vital signs remained within minimal variance pre- and post-rehabilitation. Participants proficiently engaged in all assisted exercises facilitated by the device, culminating in a high overall satisfaction rating of 4.6 ± 0.5 out of 5.

CONCLUSION

The findings indicate that the MAK device exhibits a commendable level of safety while obtaining considerable patient satisfaction during the early rehabilitation phase following TKA, suggesting this device may be a reliable adjunct to TKA protocols.

A Qualitative Analysis of the Impact of Preoperative Mindfulness-Based Stress Reduction on Total Knee Arthroplasty Surgical Experiences

We qualitatively explored the impact of preoperative mindfulness-based stress reduction (MBSR) on total knee arthroplasty (TKA) experiences. Participants (n = 10) who received MBSR prior to TKA participated in semi-structured interviews concerning their experiences with MBSR and its perceived impact on surgery. We analyzed interviews according to reflexive thematic analysis, and coded data into three main themes: 1) Impact of MBSR on surgery experiences; 2) Contributors to change; and 3) Motivations for participation. Participants noted they were able to relax, feel more confident, and cope more effectively during the preoperative period, and that others in their lives noticed positive changes following their participation in MBSR. Participants' openness to mindfulness and health-related beliefs and may have contributed to the positive impacts they experienced from MBSR. Participants described being motivated to participate in MBSR to help them prepare for their surgery and to learn new coping strategies. Participants described a strong level of commitment to the intervention. With further research, integration of MBSR into prehabilitation for TKA may be appropriate.

Pre-operative pain pressure threshold association with patient satisfaction following Total Knee Arthroplasty

Background

Total knee arthroplasty (TKA) is commonly performed for the treatment of knee osteoarthritis (KOA). Poor satisfaction continues to be seen after TKA. Whilst reasons for poor patient satisfaction are multifactorial, there is a strong correlation with persistent pain following TKA. Studies have shown an association between local and remote mechanical hypersensitivity, measured using pressure pain thresholds (PPTs), and severity of knee osteoarthritis and functional status. We aimed to determine if the pre-operative PPTs were associated with patient satisfaction following TKA.

Methods

A prospective longitudinal study of 77 individuals was undertaken. Regression modelling assessed the relationship between Patient Satisfaction using the Knee Society Score (satisfaction subscale) following TKA for KOA, and PPTs recorded pre-operatively locally and remote to the affected knee, while accounting for potentially confounding patient demographic and psychosocial factors.

Results

Lower PPTs (indicating increased mechanical hypersensitivity) locally and remote to the operative knee were modestly associated with lower patient satisfaction in the short-term (six weeks) following TKA (β 0.25-0.28, adjR2 = 0.14-0.15), independent of demographic or psychosocial influences. However, this relationship progressively diminished in the intermediate and long-term post TKA.

Conclusion

While pre-operative PPT measures may provide some foresight to patient satisfaction post TKA in the short term, these measures appear to provide little insight to patient satisfaction in the intermediate and longer term.

Genicular nerve radiofrequency ablation: a systematic review of application for perioperative pain control in total knee arthroplasty and as treatment for chronic pain in well-appearing total knee arthroplasty

BACKGROUND

Total knee arthroplasty (TKA) is a successful treatment for end-stage osteoarthritis, yet some patients still experience postoperative pain. Genicular nerve radiofrequency ablation (GNRFA) has become a potential modality to address pain in TKA. This systematic review aims to critically analyze the applicability of GNRFA in perioperative pain control prior to TKA, as well as a treatment modality for chronic painful well-appearing TKA.

METHODS

PubMed, Medline, EMBASE, Google Scholar, Scopus, and COCHRANE databases, as well as the ClinicalTrials.gov register, were reviewed. The search included randomized controlled trials and cohort studies. The sample population focused on two cohorts; those who underwent TKA and utilized intentional GNRFA as a perioperative pain control modality, and those utilizing the treatment modality for chronic pain in well-appearing TKA. GNRFA was the intervention studied, and postoperative outcomes were compared with the control group, which consisted of those not receiving GNRFA.

RESULT

Eight total publications were identified as relevant to this search. Among the pre-TKA studies, there was variability in results; these inconsistencies were attributed to a lack of standardization, especially with regard to type, timing, and targeted nerves with ablation. Likewise, while the results were improved among the population with chronic painful TKA receiving GNRFA, these inconsistencies still existed.

CONCLUSIONS

Current evidence suggests GNRFA as a possible pre-TKA intervention to potentially minimize opioid consumption, patient-reported pain, length of stay, and increased range of motion and activity. However, the short-lived duration in the setting of chronically painful well-appearing TKA represents a major barrier that warrants further investigation. Limitations include small sample size, heterogeneity, lack of standardization of techniques among studies, and lack of direct comparison and meta-analysis. Further research should focus on the standardization of technique as well as analyzing various patient and health-system-related factors that correlate with sustained positive outcomes.

Rehabilitation care for pain in elderly knee replacement patients

BACKGROUND

Total knee arthroplasty (TKA) is recognized as the most effective surgical intervention for relieving pain and improving joint mobility and deformity in patients with knee osteoarthritis and other synovial diseases. The application of accelerated postoperative rehabilitation (enhanced recovery after surgery) has demonstrated its efficacy in improving patient outcomes, and early postoperative joint function exercise has become a key prognostic factor in knee replacement. The unexpected appearance of limb pain and swelling hindered the patient's tendency for early mobilization, leading in prolonged hospitalization, delayed functional recovery and negative psychological responses.

AIM

To investigate the impact of incorporating programmed pain nursing with collaborative nursing on elderly patients undergoing knee replacement surgery.

METHODS

A retrospective analysis was conducted on a cohort of 116 patients who underwent TKA at our hospital between July 2019 and July 2021. The patients were divided into two groups: A control group (n = 58) receiving programmatic nursing, and an observed group (n = 58) receiving programmed nursing combined with a collaborative nursing model. A pain management team consisting of attending physicians, head nurses, and responsible nurses was established. Outcome measures included visual analogue scale (VAS) scores, activities of daily living (ADL) scale scores, and functional scores.

RESULTS

The ADL scores of patients in both groups exhibited a continuous increase. However, there was no statistically significant difference in the ADL scores between the two groups at 48 h and the 7th d post-surgery (P > 0.05). Upon reexamination at the 3rd mo, the observation group demonstrated higher ADL scores compared to the control group (67.48 ± 14.69 vs 59.40 ± 16.06, P < 0.05). The VAS scores of both groups significantly decreased, with no significant difference observed between the groups at each time point (P > 0.05). The functional status of patients in both groups exhibited a gradual increase prior to intervention and at the 1st, 2nd, and 3rd month following discharge (P < 0.05). There was no statistically significant difference in knee joint function scores between the two groups at the 1st month after discharge (47.52 vs 45.81, P > 0.05). However, the knee joint function scores of patients in the observation group were significantly higher than those in the control group at the 2nd (59.38 vs 53.19, P < 0.05) and 3rd month (71.92 vs 64.34, P < 0.05) following discharge.

CONCLUSION

The utilization of programmed pain nursing in conjunction with collaborative nursing for out-of-hospital care of TKA patients has demonstrated favorable outcomes, encompassing pain reduction, enhanced prognosis, and improved nursing quality for patients.

Leg length discrepancy before total knee arthroplasty is associated with increased complications and earlier time to revision

INTRODUCTION

Leg length discrepancy (LLD) following total knee arthroplasty (TKA) is a common complaint, leading to decreased patient satisfaction. However, the effect of LLD diagnosis prior to TKA on outcomes and complications is not well defined. Thus, this study aimed to assess the effects that LLD has on rates of falls and implant complications, length of stay and readmissions, and implant survivorship following TKA.

METHODS

A retrospective review of a private insurance claims database was conducted from 2010 to 2021. All cases of TKA and those with a diagnosis of leg length discrepancy were identified. Patients undergoing TKA with a diagnosis of LLD were matched to control patients 1:5 based on demographic and comorbidity profiles. Two-year fall rates and implant complications, lengths of stay, 90-day readmissions, and time to revision were compared between cohorts.

RESULTS

A total of 1,378 LLD patients were matched to 6,889 control patients. The LLD group had significantly higher rates of falls, dislocation, mechanical loosening, periprosthetic fracture, and fibrosis when compared to the control group (all P < 0.01). Additionally, mean length of stay was significantly greater in the LLD group (4.9 days vs. 3.0 days, P < 0.001). There was no significant difference in 90-day readmission rates between groups (P = 0.178). Time to revision was significantly shorter in the LLD group (392 days vs. 928 days, P < 0.001).

CONCLUSIONS

Leg length discrepancy in patients undergoing TKA was associated with significantly increased fall risk, rates of implant complications, length of stay, and faster time to revision. The findings of this study may allow orthopedic surgeons to identify those patients at risk and allow for more educated patient counseling and operative planning.

LEVEL OF EVIDENCE

III, retrospective case-control study.

Does Time Spent in the Post-Anesthesia Care Unit Affect Hospital Lengths of Stay following Primary Total Knee Arthroplasty?

Given the current healthcare economic environment, substantial efforts have been made to help streamline the in-hospital care for total knee arthroplasty (TKA) patients. While potential cost-reducing factors have been identified in the literature, analyses specifically considering post-anesthesia care unit (PACU) lengths of stay (LOS) are lacking. Therefore, the purpose of this study was to identify factors associated with (1) longer PACU LOS as well as (2) longer Hospital LOS. Prospectively collected TKA data from seven participating hospitals within a large health system were evaluated for patient demographics, body mass indices, Charlson Comorbidity Indices (CCI), surgeon volumes/training, admission types, anesthesia types, PACU LOS, and overall hospital LOS. Complete data was available for 1,690 patients (1,082 females, mean age: 67 years). Univariate and multivariate analytical models were constructed to identify which factors were predictive of longer PACU and overall hospital LOS. Same-day admissions, higher volume surgeons (≥ 100 cases per year), fellowship-trained arthroplasty surgeons, and longer operative times were associated with longer PACU LOS (p < 0.05). Multivariate analyses found age more than or equal to 65 years (β= 0.124) and CCI more than or equal to 3 (β= 0.088) to be associated with longer hospital LOS (p < 0.001). Operative times, PACU LOS, and procedure times (operative time plus PACU LOS) were not associated with longer hospital LOS (p > 0.05). These data identify associative factors for PACU LOS, as well as the influence of time spent in the PACU on overall hospital LOS. Interestingly, this analysis revealed that patients of arthroplasty fellowship-trained and higher-volume surgeons had longer PACU LOS; however, this could be explained by the observation that these particular surgeons tend to perform more complex deformity cases. Also of importance, increased PACU LOS, meaning the patient spent more time in a high-monitored setting immediately after surgery, did not necessarily confer a longer overall hospital LOS. Based on these data, it may be more beneficial to identify alternate sources than time spent in the operating room or PACU to potentially help reduce overall hospital LOS. LEVEL OF EVIDENCE:  II, prospective cohort.

A Novel Patient Selection Tool Is Highly Efficacious at Identifying Candidates for Outpatient Surgery When Applied to a Nonselected Cohort of Patients in a Community Hospital

BACKGROUND

There is a paucity of validated selection tools to assess which patients can safely and predictably undergo same-day or 23-hour discharge in a community hospital. The purpose of this study was to assess the ability of our patient selection too to identify patients who are candidates for outpatient total joint arthroplasty (TJA) in a community hospital.

METHODS

A retrospective review of 223 consecutive (unselected) primary TJAs was performed. The patient selection tool was retrospectively applied to this cohort to determine eligibility for outpatient arthroplasty. Utilizing length of stay and discharge disposition, we identified the proportion of patients discharged home within 23 hours.

RESULTS

We found that 179 (80.1%) patients met eligibility criteria for short-stay TJA. Of the 223 patients in this study, 215 (96.4%) patients were discharged home; 17 (7.9%) were on the day of surgery, and 190 (88.3%) within 23 hours. Of the 179 eligible patients for short-stay discharge, 155 (86.6%) patients were discharged home within 23 hours. Overall, the sensitivity of the patient selection tool was 79%, the specificity was 92%, the positive predictive value was 87% and the negative predictive value was 96%.

CONCLUSION

In this study, we found that more than 80% of patients undergoing TJA in a community hospital are eligible for short-stay arthroplasty with this selection tool. We found that this selection tool is safe and effective at predicting short-stay discharge. Further studies are needed to better ascertain the direct effects of these specific demographic traits on their effects on short-stay protocols.

Key Elements of Enhanced Recovery after Total Joint Arthroplasty: A Reanalysis of the Enhanced Recovery after Surgery Guidelines

Recent guidelines have produced a consensus statement for perioperative care in hip and knee replacement. However, there is still a need for reanalysis of the evidence and recommendations. Therefore, we retrieved and reanalyzed the evidence of each recommended components of enhanced recovery after surgery (ERAS) based on the guidelines of total joint arthroplasty. For each one, we included for the highest levels of evidence and those systematic reviews and meta-analyses were preferred. The full texts were analyzed and the evidence of all components were summarized. We found that most of the recommended components of ERAS are supported by evidence, however, the implementation details of each recommended components need to be further optimized. Therefore, implementation of a full ERAS program may maximize the benefits of our clinical practice but this combined effect still needs to be further determined.

Impact of the COVID-19 Pandemic on Patient Satisfaction After Total Joint Arthroplasty

The coronavirus disease 2019 (COVID-19) pandemic impacted the inpatient experience before and after total joint arthroplasty (TJA). This study aimed to examine how these changes affected patient satisfaction following TJA as recorded by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) postdischarge surveys and comments at 2 large academic institutions. A retrospective review identified patients who completed HCAHPS surveys following primary and revision TJA at 2 academic institutions: 1 in a predominately rural southern state (Institution A) and 1 in a northeastern metropolitan city (Institution B). Patients were grouped by discharge date: pre-COVID-19 (April 1, 2019, to October 31, 2019) or COVID-19 affected (April 1, 2020, to October 31, 2020). Differences in demographics, survey responses, and comment sentiments and themes were collected and evaluated. The number of HCAHPS surveys completed increased between periods at Institution A but decreased at Institution B (Institution A, 61 vs 103; Institution B, 524 vs 296). Rates of top-box survey responses remained the same across the 2 periods. The number of comments decreased at Institution B (1977 vs 1012) but increased at Institution A (55 vs 88). During the COVID-19-affected period, there was a significant increase in the negative comment rate from Institution B (11.6% vs 14.8%, P=.013) and a significant decrease in the positive comment rate from Institution A (70.9% vs 44.3%, P<.001). There was an increase in negative patient sentiments following TJA during the COVID-19 pandemic as seen in qualitative comments but not quantitative responses. This suggests that certain aspects of the TJA patient experience were impacted by COVID-19. [Orthopedics. 2023;46(2):e105-e110.].

Sleep Disturbances Following Total Knee Arthroplasty

BACKGROUND

Sleep disturbances are common after total knee arthroplasty (TKA), yet literature examining sleep and postoperative pain remains sparse. With the use of wearable devices, convenient objective remote sleep monitoring is now possible. We aimed to measure patient sleep following TKA using validated questionnaires and wearable devices to compare sleep patterns to pain scores 90 days postoperatively.

METHODS

Adult patients with body mass index < 45 undergoing unilateral primary TKA were enrolled. Patients wore a monitor, which tracked sleep duration and disturbances (getting up at least once during the night). They completed weekly Pittsburgh Sleep Quality Index (PSQI) questionnaires and visual analog scale (VAS) pain scores. Sleep patterns were compared with pain scores and sleep duration was compared with PSQI responses.

RESULTS

There were 110 patients included with 54.5% women; average age was 64 years (range, 43-80). VAS scores decreased postoperatively. PSQI overall sleep scores, sleep quantity, and sleep quality worsened for the first 30 days then improved past baseline levels by 90 days. Recorded sleep duration did not change, and recordings did not correlate at any point with VAS scores. PSQI overall score and sleep quantity did not correlate with VAS. At 30 days postoperatively, patients reporting "very bad" sleep had significantly worse VAS scores than those reporting "bad" sleep.

CONCLUSION

Patient-reported sleep quality (very bad sleep) correlated well with VAS pain score at 30 days, while sleep duration (monitored or patient-reported) did not correlate with any clinical measure and does not seem to be a useful metric in assessing TKA outcome.

Hospital Revenue, Cost, and Contribution Margin in Inpatient Versus Outpatient Primary Total Joint Arthroplasty

BACKGROUND

Removal of primary total knee arthroplasty (TKA) and primary total hip arthroplasty (THA) from the inpatient-only list has financial implications for both patients and institutions. The aim of this study was to evaluate and compare financial parameters between patients designated for inpatient versus outpatient total joint arthroplasty.

METHODS

We reviewed all patients who underwent TKA or THA after these procedures were removed from the inpatient-only list. Patients were statistical significance into cohorts based on inpatient or outpatient status, procedure type, and insurance type. This included 5,284 patients, of which 4,279 were designated inpatient while 1,005 were designated outpatient. Patient demographic, perioperative, and financial data including per patient revenues, total and direct costs, and contribution margins (CMs) were collected. Data were compared using t-tests and Chi-squared tests.

RESULTS

Among Medicare patients receiving THA, CM was 89.1% lower for the inpatient cohort when compared to outpatient (P < .001), although there was no statistical significance difference between cohorts for TKA (P = .501). Among patients covered by Medicaid or Government-managed plans, CM was 120.8% higher for inpatients receiving THA (P < .001) when compared to outpatients and 136.3% higher for inpatients receiving TKA (P < .001).

CONCLUSION

Our analyses showed that recent costs associated with inpatient stay inconsistently match or outpace additional revenue, causing CM to vary drastically depending on insurance and procedure type. For Medicare patients receiving THA, inpatient surgery is financially disincentivized leaving this vulnerable patient population at a risk of losing access to care.

LEVEL III EVIDENCE

Retrospective Cohort Study.

Wound Management following Total Knee Arthroplasty: An Updated Review

Optimal wound closure techniques following total knee arthroplasty (TKA) have focused on enhancing healing potential, preventing infection, yielding satisfactory cosmesis, and allowing early ambulation and functionality. An appropriate layered closure and management of the TKA typically involves addressing the (1) deep fascial layer; (2) subdermal layer; (3) intradermal layer, including the subcuticular region; and (4) final application of a specific aseptic dressing, each of which are covered here in detail. This focused critical review of the literature discusses traditional techniques used in all layers of wound closure following TKA while introducing several emerging popular techniques. For example, absorbable barbed skin sutures and occlusive dressings have the potential to reduce operative time, limit the need for early postoperative visits, obviate the need for suture or staple removal, and safely promote patient communication via telemedicine. As novel wound closure techniques continue to emerge and traditional approaches are improved upon, future comparative studies will assist in elucidating the key advantages of various options. In an extremely important field that has tremendous variability, these efforts may enable the reaching of a classically elusive standard of care for these techniques.

Interval Time of at Least 6 Weeks Between Bilateral Total Knee Arthroplasties is Associated With Decreased Postoperative Complications

BACKGROUND

Staged, bilateral total knee arthroplasty (TKA) has an increased risk of complications if the second procedure is performed before physiologic recovery from the first. The aims of this study were to 1) determine whether there is a time-dependent relationship between TKA staging and rates of revisions and complications and 2) identify data-driven time intervals that reduce risk of revisions and complications.

METHODS

Data were collected from a national insurance database from 2015 to 2018. Staged intervals were initially assessed using fixed 6-week intervals. Stratum-specific likelihood ratio analyses were subsequently conducted to observe data-driven staging thresholds. Bivariate and multivariable regression analyses were conducted to determine the associations between the time intervals and 2-year rates of revision surgery and 90-day major complications. We included 25,527 patients undergoing staged bilateral TKA.

RESULTS

In comparison to the shortest fixed time interval (1-6 weeks), as the staging interval increased the odds of 2-year all-cause revision and 90-day major complications significantly decreased (P < .05 for all). Stratum-specific likelihood ratio analysis identified 3 data-driven staging categories 1-5, 6-17, and 18-24 weeks that maximized the difference in both 2-year rates of revision and 90-day major complications.

CONCLUSION

Our data showed a time-dependent relationship between the timing of TKA stages and complications. If staging is considered, a delayed interval of at least 6 weeks between procedures may significantly reduce revision and major complications.

LEVEL OF EVIDENCE

Level III Therapeutic Study.

Accelerated discharge after aseptic revision knee arthroplasty is not associated with early readmission and reoperation

Aims

In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations.

Methods

Aseptic revision TKAs in the National Surgical Quality Improvement Program database were reviewed from 2013 to 2020. TKAs were stratified by length of hospital stay (greater or less than 24 hours). Patient demographic details, medical comorbidities, American Society of Anesthesiologists (ASA) grade, operating time, components revised, 30-day readmissions, and reoperations were compared. Multivariate analysis evaluated predictors of discharge prior to 24 hours, 30-day readmission, and reoperation.

Results

Of 21,610 aseptic revision TKAs evaluated, 530 were discharged within 24 hours. Short-stay patients were younger (63.1 years (49 to 78) vs 65.1 years (18 to 94)), with lower BMI (32.3 kg/m2 (17 to 47) vs 33.6 kg/m2 (19 to 54) and lower ASA grades. Diabetes, chronic obstructive pulmonary disease, hypertension, and cancer were all associated with a hospital stay over 24 hours. Single component revisions (56.8% (n = 301) vs 32.4% (n = 6,823)), and shorter mean operating time (89.7 minutes (25 to 275) vs 130.2 minutes (30 to 517)) were associated with accelerated discharge. Accelerated discharge was not associated with 30-day readmission and reoperation.

Conclusion

Accelerated discharge after revision TKA did not increase short-term complications, readmissions, or reoperations. Further efforts to decrease hospital stays in this setting should be evaluated. Cite this article: Bone Joint J 2022;104-B(12):1323–1328.

Sleep Disturbances and Disorders in Patients with Knee Osteoarthritis and Total Knee Arthroplasty

➤

There is increasing evidence that patient-reported outcomes following total knee arthroplasty (TKA) are associated with psychosocial factors and pain catastrophizing. Sleep disturbance, pain, and mental health have a complex interaction, which, if unrecognized, can be associated with impaired patient-reported outcomes and dissatisfaction following TKA.

➤

The gold standard of objective sleep assessment is polysomnography, which is not feasible to use routinely for TKA patients. Wearable devices are a validated and less costly alternative.

➤

Subjective sleep measures, such as the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, or Patient-Reported Outcomes Measurement Information System (PROMIS) computerized adaptive test sleep domains, are simple to administer and provide additional insight into sleep disturbance. Although objective and subjective measures do not correlate precisely, they can be informative together.

➤

Sleep disturbances in the elderly population are common and multifactorial in etiology, stemming from the interplay of sleep disorders, medication side effects, and pain. Commonly prescribed medications following TKA as well as postoperative pain can exacerbate underlying sleep disturbances.

➤

Obstructive sleep apnea (OSA) is prevalent in patients seeking TKA. In the setting of OSA, postoperative opioids can cause respiratory depression, resulting in consequences as severe as death. A standardized multimodal pain protocol including anti-inflammatories and gamma-aminobutyric acid (GABA) analogues may allow for decreased reliance on opioids for pain control.

➤

Surgeons should reassure patients that postoperative sleep disturbance is common and transient, collaborate with the patient's primary care doctor to address sleep disturbance, and avoid prescription of pharmaceutical sleep aids.

Perioperative medicine role in painful knee prosthesis prevention

Total knee arthroplasty is one of the most frequently performed orthopaedic surgeries. However, up to 20% of patients develop persistent postoperative pain. Persistent postoperative pain may be an extension of acute postoperative pain, but can also occur after more than 3 months without symptoms. Risk factors associated with persistent postoperative pain after arthroplasty have now been characterised within the patient's perioperative context (preoperative, intraoperative and postoperative), and can be grouped under genetic, demographic, clinical, surgical, analgesic, inflammatory and psychological factors. Identification and prevention of persistent postoperative pain through a multimodal and biopsychosocial approach is essential in the context of perioperative medicine, and has been shown to prevent or ameliorate postoperative pain.

Effects of Parecoxib Sodium Application Combined with Enhanced Recovery After Surgery Nursing on Inflammatory Factors and Knee Joint Function in Elderly Patients After Total Knee Arthroplasty

Objectives

To study the effect of parecoxib sodium (PS) application, combined with enhanced recovery after surgery (ERAS) nursing, on inflammation and knee joint function in elderly patients after total knee arthroplasty (TKA).

Methods

In this prospective cross-sectional study, we recruited 120 elderly patients treated with TKA who were randomly divided into two groups, the combine group and the control group, with 60 patients in each group. Patients in the control group received ERAS nursing and normal saline, and the patients in the combine group received ERAS nursing and PS. At different times after surgery, we compared the hemoglobin (Hb), complete white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and serum IL-1β, TNF-α, and IL-6, and recovery time for different ranges of joint motion and the knee joint function HSS (hospital for special surgery scale) score between the two groups.

Results

On the third and seventh postoperative days, the levels of Hb in the patients of the combine group were significantly lower than those in the control group (p < 0.05), while the levels of WBC, ESR, serum IL-1β, TNF-α, and IL-6 in the patients of the combine group were all significantly lower than those in the control group (p < 0.05). Compared with the patients in the control group, the recovery time for 30, 60, 90, and 120 angles of joint motion in patients of the combine group was significantly decreased (p < 0.05), and the HSS score of patients in the combine group was significantly higher than that in the control group on the first, third, and sixth postoperative months (p < 0.05).

Conclusion

Elderly TKA patients who received PS application, combined with ERAS nursing, had lower inflammation in peripheral blood 2 weeks after operation and faster postoperative recovery of knee joint function.

Risk Factors for Delayed Discharge and Adverse Outcomes Following Outpatient Billed Total Knee Arthroplasty

BACKGROUND

The volume of outpatient total knee arthroplasty (TKA) has increased with advances in perioperative protocols, patient selection, and recent policy changes regarding insurance authorization. This study analyzed 30-day outcomes from a national database to better understand risk factors for delayed discharge (length of stay [LOS] ≥1), readmission, and reoperation after outpatient TKA.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was utilized to collect TKA (CPT 27447) billed as outpatient surgery performed from 2013 to 2018. Patient demographics, comorbidities, and short-term outcomes were collected and compared in LOS 0 versus LOS ≥1 cohorts. Subgroup analysis was completed for TKA performed in 2018, after the Center for Medicare Services removal of TKA from the inpatient-only list.

RESULTS

A total of 13,669 patients had outpatient TKA performed from 2013 to 2018. Most patients had LOS ≥1 day (77.1%). The LOS 0 cohort demonstrated a lower 30-day readmission rate (1.8%) compared to LOS ≥1 (2.8%), P > .01. Both groups demonstrated a low 30-day reoperation rate, LOS 0 (0.7%) and LOS ≥1 (1.1%), P = .05. Regression analysis demonstrated risk factors for LOS ≥1 day included COPD, ASA ≥3, age >75, and BMI >35 kg/m². Regression analysis demonstrated male gender, age >75, ASA ≥3, and albumin <3.5 g/dL were risk factors for readmission. Hypertension was a risk factor for 30-day reoperation.

CONCLUSION

Risk factors for LOS ≥1 day include age >75, ASA ≥3, BMI >35 kg/m². In addition, BMI >35 kg/m² was a risk factor for readmission and reoperation. These findings reinforce appropriate patient selection when considering outpatient TKA.

Rehabilitation Approaches for Knee Arthroplasty

Up to 25% of patients after knee arthroplasty are not satisfied with the results of the operation. Revision interventions are performed in 60–80% of cases in the first 2–5 years after the primary arthroplasty. Aim. To evaluate the effectiveness of the early postoperative rehabilitation comprehensive program from the standpoint of the International Classification of Functioning (ICF) to improve the results of rehabilitation after arthroplasty. Material and methods. The results of 180 patients rehabilitation after the total knee arthroplasty (TKA) with simultaneous reconstruction of the lower limb biological axis were evaluated in two groups: I – observations (n=120), II – comparisons (n=60). Postoperative rehabilitation in the group I was carried out according to of the early rehabilitation comprehensive program after TKA, developed in the clinic, in the group II – according to the standard scheme. State of the patient was assessed by the dynamics of the pain syndrome, lower limbs muscle strength, goniometric indicators, the severity of lameness, muscle hypotrophy, limb shortening value, functional activity and quality of life. For analysis of changes in the level of damage according to the ICF, clinical tests were used. Results. From the standpoint of the ICF, the results of patients using the early postoperative rehabilitation program were equal or superior to the results of the comparison group. Conclusion. A rehabilitation program for patients after TKA, formed on the basis of a system for assessing the structural, functional and social adaptation characteristics of the patient, is effective and allows to predict the effectiveness of the rehabilitation technologies.

Rehabilitation Approaches for Knee Arthroplasty

Up to 25% of patients after knee arthroplasty are not satisfied with the results of the operation. Revision interventions are performed in 60–80% of cases in the first 2–5 years after the primary arthroplasty. Aim. To evaluate the effectiveness of the early postoperative rehabilitation comprehensive program from the standpoint of the International Classification of Functioning (ICF) to improve the results of rehabilitation after arthroplasty. Material and methods. The results of 180 patients rehabilitation after the total knee arthroplasty (TKA) with simultaneous reconstruction of the lower limb biological axis were evaluated in two groups: I – observations (n=120), II – comparisons (n=60). Postoperative rehabilitation in the group I was carried out according to of the early rehabilitation comprehensive program after TKA, developed in the clinic, in the group II – according to the standard scheme. State of the patient was assessed by the dynamics of the pain syndrome, lower limbs muscle strength, goniometric indicators, the severity of lameness, muscle hypotrophy, limb shortening value, functional activity and quality of life. For analysis of changes in the level of damage according to the ICF, clinical tests were used. Results. From the standpoint of the ICF, the results of patients using the early postoperative rehabilitation program were equal or superior to the results of the comparison group. Conclusion. A rehabilitation program for patients after TKA, formed on the basis of a system for assessing the structural, functional and social adaptation characteristics of the patient, is effective and allows to predict the effectiveness of the rehabilitation technologies.

Outcomes of an Institutional Rapid Recovery Protocol for Total Joint Arthroplasty at a Safety Net Hospital

Rapid recovery protocols (RRPs) for total joint arthroplasty (TJA) can reduce hospital length of stay (LOS) and improve patient care in select cohorts; however, there is limited literature regarding their utility in marginalized patient populations. This report aimed to evaluate the outcomes of an institutional RRP for TJA at a safety net hospital.

Intraoperative Acupuncture as Part of a Multimodal Analgesic Regimen to Reduce Opioid Usage After Total Knee Arthroplasty: A Prospective Cohort Trial

Objective: Given the U.S. opioid crisis, surgeons and anesthesiologists must collaborate to optimize nonopioid analgesics perioperatively. A common surgical procedure, total knee arthroplasty (TKA) is a critical target for opioid reduction and development of enhanced recovery protocols. Auricular therapy can help reduce pain and opioid analgesic use in the perioperative timeperiod, but intraoperative use for TKA has yet to be explored. The aim of the present study was to investigate the effect of integrating intraoperative auricular therapy as part of an opioid-sparing protocol for TKA. Materials and Methods: In this prospective cohort study, 41 patients undergoing primary unilateral TKA under neuraxial anesthesia received a standardized, opioid-free intraoperative protocol including electroauricular acupuncture. The primary outcome was the number of patients able to remain on a low-dose opioid regimen: ≤112.5 oral morphine equivalents. Additional outcomes included patient-reported pain scores, side-effects, and prior experience with acupuncture. Results: Of the 40 patients who completed the study, 26 (65%) maintained a low-dose opioid regimen, with 3 (7%) remaining opioid-free for 30 days. No subjects used opioids beyond 30 days. Mean pain scores were low at rest (Day 0: 3.4, standard deviation [SD] 2.4; Day 1: 2.4, SD 1.8) and moderate with movement (Day 0: 4.8, SD 2.6; Day 1: 5.1, SD 2.1). The most-common side-effects were dry mouth (43.2%), drowsiness (24.3%), and lightheadedness (24.3%). Conclusions: Incorporating intraoperative electroauricular acupuncture into an existing multimodal analgesia regimen is a feasible way to maintain a low-dose opioid regimen after TKA. This research was registered at clinicaltrials.gov as Clinical Trial Number: NCT#04084288.

Reduction in opioid use with perioperative non-pharmacologic analgesia in total knee arthroplasty and ACL reconstruction: a systematic review

Introduction: The world’s opioid epidemic has gotten increasingly severe over the last several decades and projects to continue worsening. Orthopedic surgery is the largest contributor to this epidemic, accounting for 8.8% of postoperative opioid dependence cases. Total knee arthroplasty (TKA) and anterior cruciate ligament (ACL) reconstruction are commonly performed orthopedic operations heavily reliant on opioids as the primary analgesic in the peri- and immediate postoperative period. These downfalls highlight the pressing need for an alternate, non-pharmacologic analgesic to reduce postoperative opioid use in orthopedic patients. The presented systematic review aimed to analyze and compare the most promising non-pharmacologic analgesic interventions in the available literature to guide future research in such a novel field. Methods: A systematic search of PubMed, MEDLINE, Embase, Cochrane, and Web of Science was performed for studies published before July 2020 based on the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, and the obtained manuscripts were evaluated for inclusion or exclusion against strict, pre-determined criteria. Risk-of-bias and GRADE (grades of recommendation, assessment, development, and evaluation) assessments were then performed on all included studies. Results: Six studies were deemed fit for inclusion, investigating three non-pharmacologic analgesics: percutaneous peripheral nerve stimulation, cryoneurolysis, and auricular acupressure. All three successfully reduced postoperative opioid use while simultaneously maintaining the safety and efficacy of the procedure. Discussion: The results indicate that all three presented non-pharmacologic analgesic interventions are viable and warrant future research. That said, because of its slight advantages in postoperative pain control and operational outcomes, cryoneurolysis seems to be the most promising. Further research and eventual clinical implementation of these analgesics is not only warranted but should be a priority because of their vast potential to reduce orthopedics surgeries’ contribution to the opioid epidemic.

Educational Attainment Affects the Early Rehabilitation of Total Knee Arthroplasty in Southwest China

Objective

To assess if the educational level of patients in Southwestern China will affect the functional recovery after total knee arthroplasty (TKA).

Methods

This retrospective study included a total of 334 patients (48 males, 286 females, with an average age of 68 years, range from 51 to 84 years) who had undergone primary unilateral TKA from March 2017 to April 2018. Patients were screened for enrollment and classified into four groups (illiterate group, the primary school group, high school group, and university group) according to their educational attainment. All patients were monitored for at least 2 years after TKA. The primary outcome was determined using the Hospital for Special Surgery knee (HSS) score at the time of follow‐up. The secondary outcomes were determined using the 12‐Item Short Form Health Survey (SF‐12) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, the satisfaction level, and complications of the surgery.

Results

Three hundred and thirty‐four patients were divided into four groups based on their highest educational level: 83 patients in the illiteracy group, 84 in the primary school group, 91 in the high school group, and 76 in the university group. They were followed up for at least 2 years. For the primary outcome, patients with high school and university education had noteworthy better HSS scores on the surgical‐side knee than those in the primary school and illiterate groups (illiteracy group 86.71 ± 5.94 vs primary school group 85.36 ± 5.88 vs high school group 89.48 ± 3.66 vs university group 88.95 ± 3.55; P < 0.05). For secondary outcomes, the mental component summary (MCS) in the university group was significantly lower than the other three groups (P < 0.05). The results of WOMAC scores were consistent with the results of the HSS score: patients in the university group and the high school group had better results when compared with the other two groups (P < 0.05). There were no statistical differences in the comparison of additional indicators and complications among the four groups, but more patients (12 peoples, 15.8%) in the university group were dissatisfied with knee function after TKA.

Conclusion

In Southwest China, patients with high school education or above can achieve better joint function after TKA but do not get better postoperative satisfaction, which may be related to the patients' higher surgical expectations for social and mental needs.

A Smartwatch Paired With A Mobile Application Provides Postoperative Self-Directed Rehabilitation Without Compromising Total Knee Arthroplasty Outcomes: A Randomized Controlled Trial

BACKGROUND

Self-directed rehabilitation (SDR) after total knee arthroplasty (TKA) has not been traditionally recommended. The purpose of this study was to determine if there was an impact on postoperative outcomes with the use of an SDR program after primary TKA.

METHODS

In this prospective, randomized, multicenter, controlled trial, we paired a smartwatch with a mobile application, providing an SDR program after TKA. Three groups were examined in this level I study: (1) control group (formal physical therapy [PT]), (2) high exercise compliance group, and (3) low exercise compliance group. Patient-reported outcome measures (PROMs) of knee injury and osteoarthritis outcome scores, joint replacement (KOOS, JR), and EuroQol five-dimension five-level (EQ-5D-5L) along with range of motion (ROM) and manipulation rates were evaluated.

RESULTS

Three hundred thirty-seven patients were enrolled in two groups with 184 in the control group and 153 in the study groups (90 in the high-compliance group and 63 in the low-compliance group). The KOOS, JR score was statistically lower in the low-compliance group in net change from preoperative scores at 3 months (P = .046) and 6 months (P = .032) than that in the control group; difference was noted at 6 months for the high-compliance group, P = .036. However, these did not meet the threshold of 8.02 units for KOOS JR minimal clinically important difference. No differences were seen in PROMs at other time intervals and in manipulation rates or ROM.

CONCLUSION

Postoperative outcomes including manipulation under anesthesia, ROM, and PROMs were not different when a smartwatch paired with a self-directed PT mobile application was compared with traditional formal PT. Surgeons can consider this an appropriate alternative to traditional PT programs after TKA.

The Effects of Dexamethasone in Diabetic Patients Undergoing Primary Total Joint Arthroplasty

Dexamethasone reduces postoperative pain and nausea, with no evidence of increased rate of infection in total joint arthroplasty. However, the effects of dexamethasone on diabetic patients undergoing total joint arthroplasty remain relatively unexplored. The purpose of this study was to examine the effects of dexamethasone on postoperative blood glucose levels, prosthetic joint infections (PJIs), and 90-day hospital returns in diabetic patients following total joint arthroplasty. Retrospective analysis was performed on 228 adult patients with a diagnosis of diabetes who underwent primary total joint arthroplasty. Patients were stratified by intraoperative dexamethasone administration. In total, 173 (75.9%) patients received intraoperative dexamethasone, with no differences in demographic variables compared with patients who did not receive dexamethasone. There was no significant difference in PJIs or 90-day hospital returns. Patients who received dexamethasone had significantly increased blood glucose concentration on Postoperative Day 1 and were significantly more likely to have blood glucose levels exceeding 180 g/dl. Although postoperative blood glucose levels were significantly increased, it is unclear what effects, if any, transient hyperglycemia may have on outcomes. The outcomes of this study support perioperative administration of dexamethasone in diabetic patients.

Artificial neural network prediction of same-day discharge following primary total knee arthroplasty based on preoperative and intraoperative variables

AIMS

This study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA).

METHODS

Data for this study were collected from the National Surgery Quality Improvement Program (NSQIP) database from the year 2018. Patients who received a primary, elective, unilateral TKA with a diagnosis of primary osteoarthritis were included. Demographic, preoperative, and intraoperative variables were analyzed. The ANN model was compared to a logistic regression model, which is a conventional machine-learning algorithm. Variables collected from 28,742 patients were analyzed based on their contribution to hospital length of stay.

RESULTS

The predictability of the ANN model, area under the curve (AUC) = 0.801, was similar to the logistic regression model (AUC = 0.796) and identified certain variables as important factors to predict same-day discharge. The ten most important factors favouring same-day discharge in the ANN model include preoperative sodium, preoperative international normalized ratio, BMI, age, anaesthesia type, operating time, dyspnoea status, functional status, race, anaemia status, and chronic obstructive pulmonary disease (COPD). Six of these variables were also found to be significant on logistic regression analysis.

CONCLUSION

Both ANN modelling and logistic regression analysis revealed clinically important factors in predicting patients who can undergo safely undergo same-day discharge from an outpatient TKA. The ANN model provides a beneficial approach to help determine which perioperative factors can predict same-day discharge as of 2018 perioperative recovery protocols. Cite this article: Bone Joint J 2021;103-B(8):1358-1366.

Return-to-Driving Recommendations After Lower-Extremity Orthopaedic Procedures

Following lower-extremity orthopaedic surgery, recommendations for safe return to driving include at least 6 to 12 weeks for a right ankle fracture, 2 days to 2 weeks for a right ankle arthroscopy, 6 to 9 weeks for a total ankle arthroplasty, 6 to 7 weeks for a right Achilles tendon rupture repair, 1 to 4 weeks for a right total knee arthroplasty, 2 weeks for a left total knee arthroplasty, 3 to 6 weeks for a right anterior cruciate ligament repair, and 1 to 4 weeks for a total hip arthroplasty. Important individual factors such as extent of injury, laterality of injury, current driving habits, type of vehicle transmission (manual or automatic), and medical comorbidities must be taken into consideration. State laws vary widely and often use vague language to describe the legal responsibilities that orthopaedic surgeons have when providing return-to-driving recommendations.

Is outpatient shoulder arthroplasty safe? A systematic review and meta-analysis

BACKGROUND

Amid rising health care costs and recent advances in surgical and anesthetic protocols, the rate of outpatient joint arthroplasty has risen steadily in recent years. Although the safety of outpatient total knee arthroplasty and total hip arthroplasty has been well established, outpatient shoulder arthroplasty is still in its infancy. The purpose of this study was to synthesize the current literature and provide further data regarding the outcomes and safety of outpatient shoulder arthroplasty.

METHODS

A systematic review was conducted following the standard PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included were studies that evaluated the outcomes of patients undergoing outpatient total shoulder arthroplasty (TSA) or reverse TSA. Meta-analysis was conducted using Mantel-Haenszel statistics to generate odds ratios (ORs) and their corresponding 95% confidence intervals (CIs) comparing outpatient and inpatient shoulder arthroplasty.

RESULTS

Twelve studies were included, with a total of 194,513 patients, of whom 7162 were outpatients. Of the studies, 8 were level III and 4 were level IV. The average age of the outpatients was 66.6 years, and the average age of the inpatients was 70.1 years. The overall OR for complications was significantly lower in outpatients (OR, 0.40; 95% CI, 0.35-0.45) than in inpatients. There was no significant difference in rates of 90-day readmission (OR, 0.88; 95% CI, 0.75-1.03), revision (OR, 0.96; 95% CI, 0.65-1.41), and infection (OR, 0.93; 95% CI, 0.64-1.35) when comparing outpatients with inpatients.

CONCLUSION

Outpatient TSA, in an appropriately selected patient population, is safe and results in comparable patient outcomes to those of inpatient shoulder arthroplasty. Given the expected increase in the number of patients requiring TSA, surgeons, hospital administrators, and insurance carriers should strongly consider the merits of a cost- and care-efficient approach to total shoulder replacement.

Perioperative medicine role in painful knee prosthesis prevention

Total knee arthroplasty is one of the most frequently performed orthopaedic surgeries. However, up to 20% of patients develop persistent postoperative pain. Persistent postoperative pain may be an extension of acute postoperative pain, but can also occur after more than 3 months without symptoms. Risk factors associated with persistent postoperative pain after arthroplasty have now been characterised within the patient's perioperative context (preoperative, intraoperative and postoperative), and can be grouped under genetic, demographic, clinical, surgical, analgesic, inflammatory and psychological factors. Identification and prevention of persistent postoperative pain through a multimodal and biopsychosocial approach is essential in the context of perioperative medicine, and has been shown to prevent or ameliorate postoperative pain.

Efficacy and safety of a self-developed home-based enhanced knee flexion exercise program compared with standard supervised physiotherapy to improve mobility and quality of life after total knee arthroplasty: a randomized control study

Background

This randomized controlled study compared standard supervised physiotherapy (SPT) with a self-developed, home-based, enhanced knee flexion exercise program involving a low stool (KFEH) in patients who underwent total knee arthroplasty (TKA).

Methods

Patients were recruited from July 2014 to December 2015 and randomly assigned to one of two groups: KFEH (n = 60) and SPT (n = 59). Outcomes (joint function) were evaluated according to the Knee Society Score (KSS), visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and range of motion (ROM) assessment at selected time points (preoperatively; 1 week; 1, 3, and 6 months; and 1 year after surgery).

Results

Pain and functional improvement were observed in both groups. Non-inferiority of KFEH was evident 12 months postoperatively; however, patients in the KFEH group exhibited better ROM at 1 month (P < 0.01). Absolute WOMAC and KSS scores were slightly better in the KFEH group, although the difference was not statistically significant. There was no difference in VAS scores and complication rates between the two groups. Additionally, the home program would save patient time and decrease the economic burden associated with in-hospital SPT.

Conclusion

Considering rehabilitation and economic efficiency as well as the COVID pandemic, a home-based enhanced knee flexion exercise program for TKA rehabilitation is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-021-02516-0.

Prospective, Single-Center Comparison of Transcranial Direct Current Stimulation Plus Electroacupuncture and Standard Analgesia in Patients After Total Knee Arthroplasty: Effect on Rehabilitation and Functional Recovery

Background

The aim of this prospective study was to compare transcranial direct current stimulation (tDCS) plus electroacupuncture with standard analgesia in patients after total knee arthroplasty (TKA) to determine the effects on rehabilitation and functional recovery.

Material/Methods

Eighty patients with osteoarthritis of the knee who underwent TKA were included in the study. They were divided into experimental (n=40) and control groups (n=40) according to postoperative analgesia method. The control group received multimodal analgesia after TKA and the experimental group received additional tDCS plus electroacupuncture. Postoperative pain, knee function, and quality of life were compared between the 2 groups.

Results

Compared with the control group, the experimental group had significantly lower visual analog scale scores at 3 and 7 days and 3 and 6 weeks after TKA (P<0.05). At 6 weeks after TKA, knee injury and osteoarthritis outcome and Hospital for Special Surgery scores and maximum knee flexion in the experimental group were significantly better than those in the control group (P<0.05). In the experimental group compared with the control group, the Short Form-36 Health Survey score also was significantly increased (P<0.05).

Conclusions

The findings from this study showed that tDCS plus electroacupuncture effectively reduced pain after TKA and improved rehabilitation and functional recovery.

Enhanced recovery protocol after single-stage bilateral primary total knee arthroplasty decreases duration of hospital stay without increasing complication rates

PURPOSE

With an increasing number of total knee arthroplasty (TKA), protocols for better standard of patient care and shorter duration of hospital stay are necessary. Enhanced recovery (ER) protocols are becoming popular to meet these objectives. The current study aims to evaluate the clinical outcome of fast-track TKA using ER protocol in terms of length of hospital stay, perioperative complications and functional outcomes.

METHODS

Patients undergoing single-stage bilateral primary TKA were prospectively included in the study. All patients went through a pre-defined ER protocol of TKA. Length of hospital stay, readmission rates, pain scores and functional scores of patients operated under ER protocol were compared with another matched historical control-group. Factors delaying the discharge of the patients by 48 h after the surgery were noted.

RESULTS

We compared 275 patients undergoing single-stage bilateral primary TKA through ER protocol (Group 1) with 190 patients who had undergone bilateral primary TKA before the ER protocol was initiated (Group 2). The length of hospital stay (3.9 ± 2.1 days in group 1 and 7.5 ± 3.2 days in group 2, p 0.0001) and post-operative pain scores at 12 h (5.2 ± 2.9 in group 1 and 5.7 ± 2.1 in group 2, p 0.03) and 24 h (4.1 ± 1.6 in group 1 and 4.6 ± 1.4 in group 2, p 0.0005) were found to be significantly better with ER protocol. There was no difference in Oxford knee scores, infection rates, readmissions or mortality between the two groups.

CONCLUSION

ER protocol in single-stage bilateral primary TKA resulted in decreased length of hospital stay without increasing complications and compromising the clinical outcome. It requires an integrated approach and adherence to clinical pathways.

LEVEL OF EVIDENCE

Level II, Prospective comparative study.

Hip and Knee Bracing: Categorization, Treatment Algorithm, and Systematic Review

Hip and knee braces or orthoses are often used to provide support after surgery and to prevent or reduce the severity of injuries. The braces are used for stabilization, immobilization, mechanical correction, and rehabilitation. Hip braces consist of stabilization and unloader variations, whereas knee braces are composed of knee sleeves and patellofemoral, prophylactic, unloader, and functional braces. Indications vary widely and depend on the type of brace. Hip braces can treat osteoarthritis to instability after total hip arthroplasty. Knee brace indications range from mild arthralgias to instability and osteoarthritis. Although braces are routinely used clinically, high-level evidence is sparse for their use. With this review, the different types and uses of hip and knee braces have been defined, and their indications exemplified in hopes of spurring future research.

Hospital Discharge Within a Day After Total Knee Arthroplasty Does Not Affect 1-Year Complications Compared With Rapid Discharge

INTRODUCTION

In patients undergoing total knee arthroplasty (TKA), it is unclear whether a difference in complication rates exists between patients discharged the day of surgery compared with subsequent postoperative days.

METHODS

Data were collected from the PearlDiver Patient Records Database from 2007 to 2017. Subjects were identified using International Classification of Diseases codes. Eligible patients were stratified into the following three groups: (1) same day discharge (<24 hours postoperatively), (2) rapid discharge (1 to 2 days), and (3) traditional discharge (3 to 4 days) based on the length of stay.

RESULTS

In total, 84,864 patients were identified as having undergone primary TKA. The incidence of same day discharge, rapid discharge, and traditional discharge was 2.36% (2,004/84,864), 28.56% (24,235/84,864), and 69.08% (58,625/84,864), respectively. After adjustment, no notable differences were observed in the overall complication and revision rates between the same day discharge group and either the rapid discharge or the traditional discharge group. On multivariate analysis, patients in the rapid discharge cohort were less likely to require manipulation under anesthesia or develop periprosthetic joint infection when compared with the traditional discharge group at 1 year postoperatively.

CONCLUSIONS

For those who qualify after careful selection, same day and rapid discharge TKA may be a feasible alternative to the traditional inpatient TKA.

LEVEL OF EVIDENCE

A level 3 retrospective, prognostic study.

Simultaneous Bilateral Primary Total Knee Arthroplasty With TXA and Restrictive Transfusion Protocols: Still a 1 in 5 Risk of Allogeneic Transfusion

BACKGROUND

Historically, there was up to a 60% risk of blood transfusion for patients undergoing simultaneous bilateral total knee arthroplasty (SBTKA). As such, the goal of this study was to analyze the rate and risk factors for allogeneic blood transfusions in patients undergoing SBTKA with tranexamic acid (TXA).

METHODS

We retrospectively identified 475 patients who underwent SBTKA with a double dose TXA regimen at a single institution from 2016 to 2019. Mean age was 65 years. Two hundred fifty-seven patients (54%) were female. Mean body mass index was 30 kg/m². Drains were utilized in 143 patients (30%). Mean preoperative hemoglobin (Hgb) was 13.7 g/dL. Multivariate logistic regression analysis adjusting for age ≥70 years, sex, body mass index, drain use, and preoperative Hgb of <12.5 g/dL was utilized to identify risk factors for transfusion.

RESULTS

One hundred six patients (22%) received an allogeneic transfusion, including 28 patients (6%) who received ≥2 units. Multivariate analysis showed that preoperative Hgb <12.5 (OR = 3.99, P < .0001), female sex (OR = 2.34, P = .002), and drain use (OR = 2.13, P = .004) were risk factors for transfusion. Forty-two patients (42/83, 51%) with a preoperative Hgb <12.5 received a transfusion compared with 64 patients (64/392, 16%) with a Hgb ≥12.5 (P < .001).

CONCLUSION

Patients undergoing SBTKA with contemporary blood management still have a 1 in 5 rate of allogeneic transfusion. Drain use independently increases transfusion risk by 2-fold and should be avoided. Patients with a preoperative Hgb <12.5 have a transfusion rate of 50% and, as such, should either not undergo SBTKA or have extensive perioperative blood optimization.

Higher patient knowledge and resilience improve the functional outcome of primary total knee arthroplasty

BACKGROUND

A significant percentage of patients have an unfavorable outcome following primary total knee arthroplasty (TKA). This study aimed to evaluate whether specific knowledge about the implant and resilience can influence the functional outcome following TKA.

METHODS

A consecutive series of 163 patients following primary TKA at a mean age of 70 years (SD 9.1 years) were included at a regional rehabilitation center between December 2015 and December 2016. Specific patient knowledge (scale 0-7), Connor Davidson Resilience Scale (CD-RISC), Western Ontario and McMaster Universities (WOMAC) score, University of California and Los Angeles (UCLA) score and constitutional parameters were assessed on admission. Pearson's correlation analysis and stepwise linear regression analysis were performed to investigate associations between knowledge, resilience and functional scores.

RESULTS

The mean overall knowledge score was 3.5 out of 7 and the mean resilience score was 72.9 out of 100. Mean WOMAC and UCLA scores on admission were 23.8 and 5.5, respectively. Stepwise linear regression analysis identified knowledge and age as significant predictors of WOMAC scores (R² = 14.3%, p = 0.003). Knowledge and resilience were identified as significant predictors of UCLA scores (R² = 13.8%, p = 0.013).

CONCLUSION

This study highlights the importance of patient-related factors as part of an integral patient care concept in TKA. Although the identified predictors still need to be refined, it could be demonstrated how better patient knowledge might ultimately lead to better functional outcome following TKA. Routinely assessing patients' resilience might be a useful tool to identify patients at risk for low activity levels.

LEVEL OF EVIDENCE

III. Patient-reported outcome study.

Is There a Synergistic Effect of Topical Plus Intravenous Tranexamic Acid Versus Intravenous Administration Alone on Blood Loss and Transfusions in Primary Total Hip and Knee Arthroplasties?

BACKGROUND

The optimal route and dosing regimen of tranexamic acid (TXA) in primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) remain unclear. As such, we sought to analyze if there was a synergistic effect of intravenous (IV) and topical TXA on blood loss and transfusions.

METHODS

We retrospectively analyzed 6720 primary TKAs and 6559 THAs performed from February 1, 2016 to December 31, 2019 at a single institution in patients who received a double IV dose (6159 TKAs and 6276 THAs) compared with a combined single IV and topical dose (561 TKAs and 283 THAs) of TXA. Multivariate logistic regression models, adjusting for age, body mass index, American Society of Anesthesiologists class, preoperative hemoglobin, and TXA administration, were performed for significant variables from a univariate analysis.

RESULTS

In the TKA cohort, the mean total blood loss was statistically similar for double IV (305 mL, 95% confidence interval [CI] = 301-310 mL) TXA compared with combined TXA (310 mL, 95% CI = 299-321 mL) (P = .43). Furthermore, there was no difference in the rate of transfusion (odds ratio = 1.23, 95% CI = 0.57-2.67, P = .598). In the THA cohort, there was statistically higher blood loss with double IV (328 mL, 95% CI = 323-333 mL) TXA than in the combined group (295 mL, 95% CI = 280-310 mL) (P < .001). The rate of transfusion was statistically similar at ~2% (P = .970).

CONCLUSIONS

A double IV TXA dose and a combined single IV and topical TXA dose were equally effective in minimizing blood transfusions (~2%) at primary TKA and THA. We did not find a synergistic effect when combining a systemic IV TXA with a topical TXA.

LEVEL OF EVIDENCE

Level III.

Preoperative Predictors of Same-Day Discharge After Total Knee Arthroplasty

Background

In January 2020, The Centers for Medicare and Medicaid Services approved total knee arthroplasty (TKA) to be performed in ambulatory surgery centers (ASCs). This study aims to develop a predictive model for targeting appropriate patients for ASC-based TKA.

Methods

A retrospective review of 2266 patients (205 same-day discharge [SDD; 9.0%] and 2061 one-day length of stay [91.0%]) undergoing TKA at a regional medical center between July 2016 and September 2020 was conducted. Multiple logistic regression was used to evaluate predictors of SDD, as these patients represent those most likely to safely undergo TKA in an ASC.

Results

Controlling for other demographics and comorbidities, patients with the following characteristics were at reduced odds of SDD: increased age (odds ratio [OR] = 0.935, P < .001), body mass index ≥35 (OR = 0.491, P = .002), female (OR = 0.535, P < .001), nonwhite race (OR = 0.456, P = .003), primary hypertension (OR = 0.710, P = .032), ≥3 comorbidities (OR = 0.507, P = .002), American Society of Anesthesiologists score ≥3 (OR = 0.378, P < .001). The model was deemed to be of adequate fit using the Hosmer and Lemeshow test (χ² = 12.437, P = .112), and the area under the curve was found to be 0.773 indicating acceptable discrimination.

Conclusion

For patients undergoing primary TKA, increased age, body mass index ≥35, female gender, nonwhite race, primary hypertension, ≥3 comorbidities, and American Society of Anesthesiologists score ≥3 decrease the likelihood of SDD. A predictive model based on readily available patient presentation and comorbidity characteristics may aid surgeons in identifying patients that are candidates for SDD or ASC-based TKA.

Medicare Total Knee Arthroplasty Patients Need Not Stay 2 Midnights for Full Facility Reimbursement

BACKGROUND

Health care systems are concerned that facility reimbursements will be reduced based on patient length of stay (LOS) of <2 midnights with the removal of total knee arthroplasty (TKA) from the inpatient-only list. The purpose of this study was to evaluate the effect of LOS and postdischarge disposition on facility reimbursement.

METHODS

We evaluated a consecutive series of 470 primary Medicare TKA patients performed at a single institution from 2018 to 2019. We analyzed facility reimbursement based on patient LOS and discharge disposition. Descriptive statistics were analyzed using chi-square test, analysis of variance, and Student t test calculations.

RESULTS

Overall, the facility was fully reimbursed in 401 patients (85%) at a mean of $11,169. The facility received full reimbursement for 323 of 326 (99%) patients with an LOS of <2 midnights who were discharged to home at a mean of $11,156. This reimbursement was significantly (P < .001) higher than patients who had an LOS <2 midnights who were discharged with home health (mean, $9773) or to a facility (mean, $10,095). For those with LOS >2 midnights, there was no difference in mean reimbursement among discharge dispositions ($11,202 vs $11,249 vs $11,085, P = .65).

CONCLUSION

In this study, Medicare TKA patients with LOS <2 midnights were fully reimbursed 99% of the time as an inpatient as long as they are discharged to home without home health or to a rehabilitation facility. Those discharged before 2 midnights who require home health service or inpatient facility are more likely to be reimbursed at a lower penalized rate.

Nursing intervention using healing touch in total knee replacement: A randomized controlled study protocol

OBJECTIVE:

To assess the efficacy of healing touch (HT) for reducing pain and promoting wound healing in patients undergoing total knee replacement (TKR).

METHOD:

The experiment will be implemented from December 2020 to December 2021 and was granted through the Research Ethics Committee of Huaihua First People's Hospital (3928/823). 60 patients are included in the study. The recruitment criteria of patients includes: 1. the willingness and ability to finish the anxiety and pain questionnaires; 2. the clinical indication of TKR on the basis of medical history and physical examination; and 3. above the age of 60 years. The exclusionary criteria includes: 1. unable to cooperate with the postoperative evaluation and treatment; 2. revision of TKR; 3. diagnosis of the rheumatoid arthritis; and 4. having surgical complications. The measurement of pain is conducted by the visual analog scale, while the levels of anxiety is measured with the State-Trait Anxiety Inventory. For all data, they are analyzed through using the software of IBM SPSS Statistics for Windows, version 20 (IBM Corp., Armonk, NY, USA).

RESULTS:

Table 1 indicates the comparison of clinical outcomes between the control group and study group.

CONCLUSION:

HT appears to reduce the postoperative pain and improve patient satisfaction after TKR.

The effects of kinesiophobia on outcome following total knee replacement: a systematic review

INTRODUCTION

Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR.

MATERIALS AND METHODS

A primary search of electronic databases, grey literature, and trial registries was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Outcome measures were grouped into short (< 6 months), medium (6-12 months), and long term (> 12 months). Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials.

RESULTS

All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12 months in three studies (r = 0.20 p < 0.05, R = 0.317 p = 0.001, and correlation coefficient 0.197 p = 0.005). TSK score significantly correlated with mean active range of motion (ROM) at 2 weeks [65.98 (SD = 14.51) versus 47.35 (SD = 14.48) p = 0.000], 4 weeks [88.20 (SD = 15.11) versus 57.65 (SD = 14.80) p = 0.000], and 6 months [105.33 (SD = 12.34) versus 85.53 (SD = 14.77) p = 0.000] post-operation. Three post-operative interventions improved TSK score vs control following TKR: a home-based functional exercise programme [TSK - 14.30 (SD = 0.80) versus - 2.10 (SD = 0.80) p < 0.001], an outpatient cognitive behavioural therapy (CBT) programme [TSK 27.76 (SD = 4.56) versus 36.54 (SD = 3.58)], and video-based psychological treatment [TSK 24 (SD = 5) versus 29 (SD = 5) p < 0.01].

CONCLUSIONS

Kinesiophobia negatively affects functional outcomes up until 1 year post-operatively, while active ROM is reduced up to 6 months post-procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR.

The effect of immediate post-operative knee range of motion photographs on post-operative range of motion after total knee arthroplasty : An assessor-blinded randomized controlled clinical trial in sixty patients

PURPOSE

We attempted to determine the effect of immediate post-operative knee range of motion (ROM) photographs on improving ROM after total knee arthroplasty (TKA).

METHODS

Sixty patients, scheduled for unilateral primary TKA, were randomized into two groups. The photo group (n = 30) were immediately shown post-TKA knee ROM photographs as motivation for rehabilitation. The non-photo group (n = 30) received identical post-operative pain control and rehabilitation programs. Post-operative knee ROM and Knee Society Scores (KSS) at day three, six weeks, three months, six months, one year, and two years were evaluated. Outcome assessors were blinded to the groups during the study.

RESULTS

Patients in the photo group had better knee flexion on day three (99.9° ± 15.3°, 95% confidence interval (CI) 94.1-105.7° vs. 92.3° ± 11.4°, 95% CI 87.9-96.8°; p = 0.038) and at six weeks (120.9° ± 13.4°, 95% CI 115.7-126.0° vs. 112.5° ± 13.6°, 95% CI 107.2-117.8°; p = 0.023); however, there were no differences in range of flexion beyond six weeks post-operatively. Knee extension did not significantly differ throughout. Clinical KSS was significantly higher in the photo group at six weeks (90.7° ± 6.2° vs. 86.6° ± 6.4°, p = 0.017). Functional KSS showed no differences between groups during follow-up.

CONCLUSION

Showing knee ROM photographs seemed to result in significant improvement of knee flexion and clinical KSS in the first 6 weeks post-TKA and may be recommended as part of post-TKA rehabilitation.

The Impact of Femoral Nerve Anesthesia on Short-Term Clinical Outcomes and Opioid Claims After Total Knee Arthroplasty

Background

The impact of femoral nerve blocks (FNBs) during primary total knee arthroplasty (TKA) on clinical outcomes and pain management remains unclear. The present research investigates the impact that continuous and single-shot FNBs during TKA have on postoperative opioid claims and short-term clinical outcomes.

Methods

An administrative claims database was queried to identify patients who underwent primary TKA with a continuous FNB, single-shot FNB, or no FNB. More than 300,000 patients were analyzed from the database. Rates of opioid claims were compared via achi-square analysis. Incidence of postoperative complications was compared with multivariable logistic regression.

Results

Patients receiving a FNB had a significantly higher risk of falls both at 6 months (odds ratio [OR], 1.30) and 1 year postoperatively (OR, 1.25), as well as readmissions within 90 days (OR, 1.18) compared with patients without FNBs. The FNB cohort exhibited a higher risk of deep vein thrombosis (OR, 1.57), myocardial infarction (OR, 1.79), and cerebrovascular accident (OR, 1.20) during the inpatient stay. Relative to single-shot FNBs, continuous FNBs were associated with a higher risk of readmissions within 90 days and systemic complications, although the risk varied by age, sex, and Charlson Comorbidity Index score. More patients without FNBs filed opioid claims within 1 year postoperatively, but the average total morphine milligram equivalents prescribed was comparable to patients who received FNBs.

Conclusions

FNBs during TKA place patients at a significantly higher risk of falls, readmissions, and systemic complications in the short term. The risk of readmission and systemic complications was higher for continuous FNBs. More patients without FNBs filed opioid claims postoperatively than patients who received FNBs.

Rapid Versus Standard Recovery Protocol Is Associated With Improved Recovery of Range of Motion 12 Weeks After Total Knee Arthroplasty

INTRODUCTION

With the increasing demand for total knee arthroplasty (TKA), rapid recovery protocols (RRPs) have been introduced to reduce costs and the length of stay (LOS). Little is known about the effects of RRPs on postoperative knee range of motion (ROM).

METHODS

We reviewed the medical charts of 323 patients who underwent primary TKA performed by a single orthopaedic surgeon at a university-based orthopaedic tertiary care safety net practice. Of the 323 patients, 129 were treated with a standard recovery protocol (SRP) between January 1, 2012, and December 10, 2013, and 194 with a RRP beginning December 11, 2013. Knee ROM was assessed at the preoperative visit and at scheduled postoperative visits for up to 1 year. Differences in mean LOS between the groups were compared using a Poisson regression with and without adjustment for covariates. Repeated measures analysis of covariance was used to evaluate the effects of recovery protocol, time, and the interaction of recovery protocol by time on flexion and flexion contracture. The probability of achieving flexion ≥120° and having a flexion contracture ≥10° was estimated using the SAS/STAT GLIMMIX procedure with a binary distribution and a logit link.

RESULTS

The mean LOS for the RRP and SRP groups was 0.8 and 2.5 days, respectively. RRP was associated with greater flexion at 2, 6, and 12 weeks and a higher probability of attaining flexion ≥120° at 6 and 12 weeks. Patients receiving a RRP had less severe flexion contracture and a lower probability of flexion contracture ≥10° at 2, 6, and 12 weeks.

DISCUSSION

During the first 12 weeks after TKA, patients who received a RRP had a markedly greater ROM than patients who received a SRP, suggesting that RRP may allow patients to do a greater variety of activities of daily living during the first 3 postoperative months while reducing health care costs.

LEVEL OF EVIDENCE

Level III.

The effects of immediate programmed cryotherapy and continuous passive motion in patients after computer-assisted total knee arthroplasty: a prospective, randomized controlled trial

Background

The postoperative nursing intervention with immediate cryotherapy and continuous passive motion (CPM) remains elusive regarding the postoperative pain and range of motion (ROM) for patients undergoing computer-assisted total knee arthroplasty (CAS-TKA).

Methods

A prospective, randomized controlled trial with a purposive sampling method was utilized. Sixty patients scheduled for a unilateral CAS-TKA at a medical center were randomly assigned to the intervention group (n = 30) and control group (n = 30). The intervention group applied programed cryotherapy and CPM within 1 h while returning to the ward on the day of surgery, while the control group did not. Data were analyzed using mixed models to compare the numeric rating scale (NRS) for pain, ROM, and swelling at postoperative day (POD) 4.

Results

There was no significant difference in the NRS score between the groups (p = 0.168). The intervention group had significantly higher ROM than the control group (98° vs. 91°, p = 0.004) at POD 4. Although no significant difference in joint swelling was found between groups (p = 0.157), the intervention group had lower mean joint swelling (32.2 cm) than the control group (33.9 cm).

Conclusions

Immediate programmed cryotherapy and continuous passive motion could help to improve ROM quickly after CAS-TKA. It should be incorporated into the daily nursing plan for patients undergoing CAS-TKA.

Trial registration

ClinicalTrials.gov, NCT04136431. Registered 23 October 2019—retrospectively registered