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Rana P, Brennan J, Johnson A, Turcotte J, MacDonald JH, King P. The association between losartan potassium prescription and postoperative outcomes following total knee arthroplasty: A TriNetX analysis. Orthop Traumatol Surg Res 2024; 110:103851. [PMID: 38428487 DOI: 10.1016/j.otsr.2024.103851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/19/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a common surgical procedure performed to alleviate pain and improve functional outcomes in patients with knee osteoarthritis and rheumatoid arthritis who have failed conservative treatments. Arthrofibrosis has been extensively studied due to its negative impact on TKA outcomes. Losartan, an angiotensin receptor blocker (ARB), has the potential to improve TKA outcomes by inhibiting TGF-β and decreasing fibrosis. This study aims to analyze a large-scale, real-world healthcare database to investigate the association between losartan potassium prescription and postoperative outcomes such as readmissions, ED visits, and the need for MUA or revision TKA. HYPOTHESIS Based on previous literature and the nature of ARBs, it is expected that the addition of losartan will aid in better outcomes for patients following a primary TKA. PATIENTS AND METHODS In this retrospective observational study, the TriNetX Research Network (TriNetX) database was queried as of June 21, 2023. All patients who underwent a primary total knee arthroplasty (TKA) prior to June 21, 2022 were included. Patients were then divided into two cohorts by whether they had an active losartan potassium prescription within the year prior to their surgery to within 90days postoperatively. Patients were then propensity-matched to eliminate differences in demographics and comorbidities. RESULTS Losartan TKA patients were 1.18 [OR: 0.85 (95% CI: 0.79-0.90), p<0.001] times less likely to be readmitted within 90days and were 1.15 (OR: 0.87 (95% CI: 0.79-0.96); p=0.009) times less likely to undergo a manipulation under anesthesia (MUA) within the 1-year postoperative period. There were no statistically significant differences in rates of emergency department (ED) visits at 90days postoperatively or revision TKAs at 1year postoperatively. DISCUSSION In conclusion, patients with an active losartan prescription prior to TKA had a significantly lower likelihood of readmission within 90days and a lower likelihood of undergoing MUA within the 1-year postoperative period compared to patients not taking losartan. This presents an opportunity for further clinical investigation to explore the value of losartan in TKA. LEVEL OF EVIDENCE III; an observational cohort study.
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Affiliation(s)
- Parimal Rana
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
| | - Jane Brennan
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
| | - Andrea Johnson
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
| | - Justin Turcotte
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States.
| | - James H MacDonald
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
| | - Paul King
- Luminis Health Orthopedics, Anne Arundel Medical Center, 2000 Medical Parkway, Suite 503, Annapolis, MD 21401, United States
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Szapary HJ, Farid A, Desai V, Franco H, Ready JE, Chen AF, Lange JK. Predictors of reoperation and survival experience for primary total knee arthroplasty in young patients with degenerative and inflammatory arthritis. Arch Orthop Trauma Surg 2024; 144:4085-4094. [PMID: 38613613 DOI: 10.1007/s00402-024-05299-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/24/2024] [Indexed: 04/15/2024]
Abstract
INTRODUCTION While total knee arthroplasty (TKA) is typically implemented in patients > 65 years old, young patients may need to undergo TKA for pain relief and functional improvement. Current data are limited by older cohorts and short-term survival rates. This study aimed to examine a large sample size of patients with degenerative and inflammatory conditions who underwent primary TKA at a young (≤ 40) age to identify predictors of reoperation, as well 15-year survivorship. MATERIALS AND METHODS A retrospective study was performed on 77 patients (92 surgeries) who underwent primary TKA at ≤ 40 years old, between January 1990 and January 2020. Patient charts were reviewed and a multivariable logistic regression model identified independent predictors of reoperation. Kaplan-Meier analysis was employed to build survival curves and log-rank tests analyzed survival between groups. RESULTS Of the 77 patients, the median age at the time of surgery was 35.7 years (IQR: 31.2-38.7) and median follow-up time was 6.88 years. Twenty-one (22.8%) primary TKAs underwent 24 reoperations, most commonly due to stiffness (n = 9, 32.1%) and infection (n = 13, 46.4%) more significantly in the OA group (p = 0.049). There were no independent predictors of reoperation in multivariable analysis, and 15-year revision-free survivorship after TKA did not differ by indication (77.3% for OA/PTOA vs. 96.7% for autoimmune, p = 0.09) or between ≤ 30 and 31-40 year age groups (94.7% vs. 83.6%, p = 0.55). CONCLUSIONS In this cohort of patients ≤ 40 years old, revision-free survival was comparable to that reported in the literature for older TKA patients with osteoarthritis/autoimmune conditions (81-94% at 15-years). Though nearly a quarter of TKAs required reoperation and causes of secondary surgery differed between degenerative and inflammatory arthritis patients, there were no significant predictors of increased reoperation rate. Very young patients ≤ 30 years old did not have an increased risk of revision compared to those aged 31-40 years.
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Affiliation(s)
- Hannah J Szapary
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA.
| | - Alexander Farid
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Vineet Desai
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - Helena Franco
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
- Harvard Medical School, 25 Shattuck St, Boston, MA, 02115, USA
| | - John E Ready
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
| | - Jeffrey K Lange
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA
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Olsen AA, Junge JM, Booth G, Abraham VM, Balazs GC, Goldman AH. A Lack of Generalizability-Total Knee Demographics in the Active Duty Population. Mil Med 2024; 189:e1161-e1165. [PMID: 37966515 DOI: 10.1093/milmed/usad437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/16/2023] Open
Abstract
INTRODUCTION Age and sex are known demographic risk factors for requiring revision surgery following primary total knee arthroplasty (TKA). Military service members are a unique population with barriers to long-term follow up after surgery. This study aims to compare demographic data between active duty military personnel and a nationwide sample to identify differences that may impact clinical and economic outcomes. METHODS A retrospective observational analysis was performed using the Military Health System Data Repository (MDR) and the National Surgical Quality Improvement Program (NSQIP). Databases were queried for patients undergoing primary TKA between January 1, 2015 and December 31, 2020. The MDR was queried for demographic data including age, sex, duty status, facility type, geographic region, history of prior military deployment, history of deployment-related health condition, branch of military service, and military rank. National Surgical Quality Improvement Program was queried for age and sex. Median age between populations was compared with the Mann-Whitney U test, and gender was compared with a chi-squared test. RESULTS During the study period, 2,094 primary TKA patients were identified from the MDR, and 357,865 TKA patients were identified from the NSQIP database. Military TKA patients were 79.4% male with a median age of 49.0, and NSQIP TKA patients were 38.9% were male, with a median age of 67. Military TKA patients were significantly more likely to be male (P < .001) and younger (P < .001). CONCLUSION Patients undergoing TKA in the military are younger and more likely to be male compared to national trends. Current evidence suggests these factors may place them at a significant revision risk in the future. The application of quality metrics based on nationwide demographics may not be applicable to military members within the Military Health System.
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Affiliation(s)
- Aaron A Olsen
- Department of Orthopaedic Surgery, Bone and Joint Sports Medicine Institute, Portsmouth, VA 23708, USA
| | - Joshua M Junge
- Department of Anesthesia, Naval Medical Center, Portsmouth, VA 23708, USA
| | - Greg Booth
- Department of Anesthesia, Naval Medical Center, Portsmouth, VA 23708, USA
| | - Vivek M Abraham
- Department of Orthopaedic Surgery, Bone and Joint Sports Medicine Institute, Portsmouth, VA 23708, USA
| | - George C Balazs
- Department of Orthopaedic Surgery, Bone and Joint Sports Medicine Institute, Portsmouth, VA 23708, USA
| | - Ashton H Goldman
- Department of Orthopaedic Surgery, Bone and Joint Sports Medicine Institute, Portsmouth, VA 23708, USA
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Debbi EM, Chandi SK, Cororaton AD, Nguyen J, Westrich GH, Sculco PK, Chalmers BP. Range-of-Motion Predictors for Repeat Manipulation Under Anesthesia and Revision Surgery for Stiffness After Total Knee Arthroplasty. HSS J 2024:15563316241254086. [PMID: 39564403 PMCID: PMC11572502 DOI: 10.1177/15563316241254086] [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: 12/06/2023] [Accepted: 03/26/2024] [Indexed: 11/21/2024]
Abstract
Introduction Manipulation under anesthesia (MUA) is a first-line treatment for stiffness after total knee arthroplasty (TKA), but predicting outcomes after MUA can be difficult. Purpose We sought to determine the association between pre-MUA range-of-motion (ROM) and the risk of repeat MUA and revision in patients who underwent primary TKA. Methods We conducted a retrospective review of 543 MUAs for stiffness at a single institution. Mean age was 62.5 years, and 64% were female. Second MUA or revision TKA were considered failures of treatment. Penalized logistic regression models were used to assess risk factors for failures. The Kaplan-Meier survivorship was used to examine survivorship free from second MUA or revision. Results Before and after MUA, there was significant improvement in knee flexion (78.0° vs 112.8°, respectively) and extension (4.1° vs 0.8°, respectively); 6.4% of patients required repeat MUA and 5.3% required revision TKA. Survivorship free of second MUA was 90.9%, revision for stiffness was 92.4%, and all-cause revision was 88.2% at 2 years post-MUA. Patients with pre-MUA flexion contracture of ≥5° were more likely to undergo second MUA revision for stiffness and any revision. There were significant improvements in patient-reported outcomes postoperatively. Conclusions This retrospective chart review suggests that MUA is an effective treatment for post-TKA stiffness, with good early survivorship, and that worse pre-MUA ROM is associated with MUA failure and need for repeat MUA or revision. This information may have implications for patient counseling and management.
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Affiliation(s)
- Eytan M Debbi
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Sonia K Chandi
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | | | - Joseph Nguyen
- Biostatistics Core, Hospital for Special Surgery, New York, NY, USA
| | - Geoffrey H Westrich
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Peter K Sculco
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Brian P Chalmers
- Division of Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, USA
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Puri S, Alpaugh K, Chiu YF, Ast MP, Jerabek S, Westrich G, Chalmers B. Cementless Versus Cemented Total Knee Arthroplasty of the Same Design: Shorter Operative Times and Minimal Differences in Early Outcomes. HSS J 2024; 20:202-207. [PMID: 39282002 PMCID: PMC11393630 DOI: 10.1177/15563316231179220] [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: 01/08/2023] [Accepted: 04/05/2023] [Indexed: 09/18/2024]
Abstract
Introduction: Modern primary cementless total knee arthroplasty (TKA) is increasingly popular, but there is limited evidence on its benefits, early complications, and failures. Purpose: We sought to evaluate operative time, early survivorship, and outcomes of cementless versus cemented TKA of the same design. Methods: As part of this single-center, multisurgeon, retrospective cohort study, we reviewed 598 primary, unilateral TKAs (170 cementless, 428 cemented) of the same design from 2016 to 2018. The cementless cohort was younger (63 vs 67 years) and had more cruciate-retaining implants (17% vs 12%) compared with the cemented cohort. We compared operative time, length of stay, and complications. Survivorship curves were generated via the Kaplan-Meier method. Results: Patients with cementless TKA (using the Triathlon implant, Stryker) had a 24% reduction in operative time (83 vs 109 minutes) but similar length of stay compared with those with cemented TKA (57 vs 61 hours). Cementless TKA had a higher rate of postoperative manipulation for stiffness compared with cemented TKA (8% vs 3%), but there were notable demographic differences between the cohorts. Despite 2 cases (1%) of early cementless tibial aseptic loosening requiring component revision compared with none in the cemented cohort, there was no difference in revision-free survivorship at 2 years (96% and 98%, respectively). Conclusion: This retrospective cohort study found that cementless TKA had a 24% reduction in operative time compared with cemented TKA and similar short-term survivorship. There was a slightly higher rate of aseptic revision and manipulation in the cementless cohort. Further study is warranted on the long-term durability of cemented and cementless TKAs to determine if cementless fixation proves more durable in the midterm to long term.
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Affiliation(s)
- Simarjeet Puri
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Kyle Alpaugh
- Center for Hip & Knee Replacement, Massachusetts General Hospital, Boston, MA, USA
| | - Yu-Fen Chiu
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Michael P Ast
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Seth Jerabek
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Geoffrey Westrich
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Brian Chalmers
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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Edgar M, Harvey J, Jiang S, Walters J, Kozina E, Kaplan N, Redondo M, Zabawa L, Chmell S. Cemented total knee arthroplasty provides greater knee range of motion at 2 years than cementless technique. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3561-3568. [PMID: 37231309 DOI: 10.1007/s00590-023-03596-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Optimal fixation method between cemented, cementless, and hybrid techniques for total knee arthroplasty (TKA) is still debated. The purpose of this study is to evaluate the clinical outcomes of patients undergoing cemented versus cementless TKA. METHODS We reviewed 168 patients who underwent a primary TKA at a single academic institution between January 2015 and June 2017. Patients were categorized into cemented (n = 80) or cementless (n = 88) groups. Only patients with greater than or equal to 2-year follow-up were included in the study. Multivariate regressions were performed to analyze the relationship between the surgical fixation technique and the clinical outcomes. RESULTS There were no differences in demographics or baseline operative characteristics between the two groups. The cemented group had fewer manipulations under anesthesia (MUA) (4 vs. 15, p = 0.01), longer intraoperative tourniquet times (101.30 vs. 93.55 min, p = 0.02), and increased knee range of motion (ROM) at final follow-up (111.48 vs. 103.75°, p = 0.02) compared to the cementless group. DISCUSSION AND CONCLUSION Both cemented and cementless component fixation are viable options for (TKA). This study found that patients who underwent a cemented TKA required fewer MUA's and had greater final ROM compared to patients undergoing cementless TKA. Additional research is required regarding cementless and cemented fixation. We believe that the choice of which fixation technique to use ultimately comes down to patient characteristics and surgeon preference.
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Affiliation(s)
- Michael Edgar
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA.
| | - Jack Harvey
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Sam Jiang
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Jhunelle Walters
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Erik Kozina
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Nicholas Kaplan
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Michael Redondo
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Luke Zabawa
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
| | - Samuel Chmell
- University of Illinois College of Medicine at Chicago, Chicago, IL, 60612, USA
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Sheridan GA, Neufeld ME, Howard LC, Greidanus NV, Garbuz DS, Masri BA. The Impact of Changing Total Knee Arthroplasty Implants at a High-Volume Institution. J Arthroplasty 2022; 37:1759-1762. [PMID: 35469987 DOI: 10.1016/j.arth.2022.04.023] [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: 02/22/2022] [Revised: 03/28/2022] [Accepted: 04/18/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The ability of a group of high-volume arthroplasty surgeons to simultaneously change their preferred primary total knee arthroplasty (TKA) implant of choice to another, has not been explored in the literature to date. The main hypothesis was that such a change could be made with no significant impact on clinical outcomes. METHODS This is a retrospective cohort study comparing the last 500 consecutive TKAs implanted of a routinely used TKA implant (NexGen; Zimmer, Warsaw, IN) with the first 500 consecutive TKAs implanted of a newly adopted TKA implant (Triathlon; Stryker, Mahwah, NJ) at an institutional level. Primary outcomes of importance included all complications that occurred either intraoperatively or early postoperatively, early all-cause revision rate, and early reintervention rate. RESULTS There was a 1.2% (n = 6) complication rate in the NexGen cohort compared to 0.8% (n = 4) in the newly adopted Triathlon cohort (P = .75). The rate of intraoperative fracture was 1% in the NexGen cohort and 0.6% in the Triathlon cohort (P = .72). The early all-cause revision rate for the NexGen TKA was 1% (n = 5) compared to 0.8% (n = 4) in the Triathlon cohort (P = 1.0). The manipulation under anesthesia (MUA) rate in the NexGen cohort was 2.4% compared to 4.6% in the Triathlon cohort (P = .058). The only predictor variable associated with MUA rate was American Society of Anesthesiologists grade, where there was a significantly lower rate of MUA with a higher American Society of Anesthesiologists grade (P = .042). CONCLUSION It is possible to implement the institution-wide adoption of an established, high-performing TKA implant without any negative implications in relation to early revision rates, perioperative complication rates, and reintervention rates. This study is the first of its kind to be reported in the literature.
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Affiliation(s)
- Gerard A Sheridan
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael E Neufeld
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa C Howard
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nelson V Greidanus
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald S Garbuz
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bassam A Masri
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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Yang DS, Lemme NJ, Glasser J, Daniels AH, Antoci V. The Effect of Early versus Late Manipulation Under Anesthesia on Opioid Use, Surgical Complications, and Revision Following Total Knee Arthroplasty. J Knee Surg 2022. [PMID: 35817059 DOI: 10.1055/s-0042-1749607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Previous studies of early versus late manipulation under anesthesia (MUA) do not report on postoperative opioid utilization or revisions and focused on small single-institution retrospective cohorts. The PearlDiver Research Program (www.pearldiverinc.com), which uses an all-inclusive insurance database, was used to identify patients undergoing primary total knee arthroplasty (TKA) who received (1) late MUA (>12 weeks), (2) early MUA (≤12 weeks), or (3) TKA only. To develop the control group cohort of TKA-only patients, 3:1 matching was conducted using 11 risk factor variables deemed significant by chi-squared analysis. Complications and opioid utilization were compared through multivariate regression analysis, controlling for age, gender, and Charlson Comorbidity Index. The risk of TKA revision was assessed through Cox-proportional hazards modeling and Kaplan-Meier survival analysis with log-rank test. Between 2011 and 2017, 2,062 TKA patients with early MUA, 1,112 TKA patients with late MUA, and a control cohort of 8,327 TKA-only patients were identified in the database. The percent of patients registering opioid use decreased from 54.6% 1 month pre-MUA to 4.6% (p < 0.0001) 1 month post-MUA following early MUA, whereas only from 32.6 to 10.4% (p < 0.0001) following late MUA. Late MUA was associated with higher risk of repeat MUA at 6 months (adjusted odds ratio [aOR] = 2.74, p < 0.0001), 1 year (aOR = 2.66, p < 0.0001), and 2 years (aOR = 2.63, p < 0.0001) following index MUA. Hazards modeling and survival analysis showed increased risk of TKA revision following late MUA (adjusted hazard ratio [aHR] = 3.50, 95% confidence interval [CI]: 2.77-4.43, p < 0.0001) compared to early MUA (aHR = 2.15, 95% CI: 1.72-2.70, p < 0.0001), with significant differences in survival to revision curves (p < 0.0001). When compared to early MUA at 1 year, late MUA was associated with a significantly increased risk of prosthesis explantation (aOR = 2.89, p = 0.0026 vs. aOR = 0.93, p = 0.8563). MUA within 12 weeks after index TKA had improved pain resolution and significant curtailing of opioid use. Furthermore, late MUA was associated with prolonged opioid use, increased risks of revision, as well as prosthesis explantation, supporting screening and early intervention in cases of slow progression and stiffness. The level of evidence of this study is III.
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Affiliation(s)
- Daniel S Yang
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nicholas J Lemme
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jillian Glasser
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Valentin Antoci
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Courage O, Strom L, van Rooij F, Lalevée M, Heuzé D, Papin PE, Butnaru M, Müller JH. Higher rates of surgical and medical complications and mortality following TKA in patients aged ≥ 80 years: a systematic review of comparative studies. EFORT Open Rev 2021; 6:1052-1062. [PMID: 34909224 PMCID: PMC8631241 DOI: 10.1302/2058-5241.6.200150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The purpose of this systematic review was to synthesize studies published since the last systematic review in 2015 that compare outcomes of primary total knee arthroplasty (TKA) in older patients (≥ 80 years) and in younger patients (< 80 years), in terms of complication rates and mortality. An electronic literature search was conducted using PubMed, Embase®, and Cochrane Register. Studies were included if they compared outcomes of primary TKA for osteoarthritis in patients aged 80 years and over to patients aged under 80 years, in terms of complication rates, mortality, or patient-reported outcomes (PROs). Thirteen studies were eligible. Surgical complications in older patients ranged from 0.6–21.1%, while in younger patients they ranged from 0.3–14.6%. Wound complications in older patients ranged from 0.5–20%, while in younger patients they ranged from 0.8–22.0%. Medical complications (cardiac, respiratory, thromboembolic) in older patients ranged from 0.4–17.3%, while in younger patients they ranged from 0.2–11.5%. Mortality within 90 days in older patients ranged between 0–2%, while in younger patients it ranged between 0.0–0.03%. Compared to younger patients, older patients have higher rates of surgical and medical complications, as well as higher mortality following TKA. The literature also reports greater length of stay for older patients, but inconsistent findings regarding PROs. The present findings provide surgeons and older patients with clearer updated evidence, to make informed decisions regarding TKA, considering the risks and benefits within this age group. Patients aged over 80 years should therefore not be excluded from consideration for primary TKA based on age alone.
Cite this article: EFORT Open Rev 2021;6:1052-1062. DOI: 10.1302/2058-5241.6.200150
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Affiliation(s)
| | | | | | - Matthieu Lalevée
- Ramsay Santé, Hopital Prive de l'Estuaire, LeHavre, France.,Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
| | - Donatien Heuzé
- Ramsay Santé, Hopital Prive de l'Estuaire, LeHavre, France.,Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
| | - Pierre Emanuel Papin
- Ramsay Santé, Hopital Prive de l'Estuaire, LeHavre, France.,Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
| | - Michael Butnaru
- Ramsay Santé, Hopital Prive de l'Estuaire, LeHavre, France.,Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
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Chalmers BP, Lebowitz J, Chiu YF, Joseph AM, Padgett DE, Bostrom MP, Della Valle AG. Reduction of Opioid Quantities at Discharge After TKA Did Not Increase the Risk of Manipulation Under Anesthesia: An Institutional Experience. J Arthroplasty 2021; 36:2307-2312. [PMID: 33691999 DOI: 10.1016/j.arth.2021.02.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 02/10/2021] [Accepted: 02/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In response to the opioid epidemic, our arthroplasty service sequentially reduced the opioid quantities prescribed at primary total knee arthroplasty (TKA) discharge. However, its effect on postdischarge pain control and rehabilitation is unknown. We assessed if this decrease was associated with an increase in the risk of manipulation under anesthesia (MUA). METHODS We retrospectively reviewed 8799 patients undergoing primary TKA from 2016 to 2019 at a single institution. There were two institution-wide reductions in the amount of opioids prescribed at discharge; therefore, we divided patients into 3 periods (P1, P2, and P3). The mean discharge morphine milligram equivalents (MMEs) went from 900 MMEs to ~525 MMEs to ~320 MMEs in P1, P2, and P3, respectively. We analyzed MUA rates and if lower discharge MMEs was a risk factor for MUA in a multivariate model. We also compared refill patterns (rates, number, refill MMEs, and total MMEs) between MUA and non-MUA patients. RESULTS The rate of MUA did not increase with reduced discharged opioids (5.5% in P1, 5.8% in P2, and 4.6% in P3, P = .74). In a multivariate analysis, discharge MMEs of <450 was not a significant risk factor for MUA. However, a diagnosis of chronic pain (OR = 1.86, P < .001) and an elevated body mass index (OR = 1.02 per unit increase, P < .001) were significant risk factors. We did not find significant differences in any opioid prescription refill patterns in MUA and non-MUA patients. CONCLUSION Serial reductions in discharge MMEs after primary TKA did not significantly affect the rate of MUA, a surrogate marker for pain control and the rehabilitative process.
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Affiliation(s)
- Brian P Chalmers
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Juliana Lebowitz
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Yu-Fen Chiu
- Biostatistics Core, Research Administration, Hospital for Special Surgery, New York, NY
| | - Amethia M Joseph
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Douglas E Padgett
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Mathias P Bostrom
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Alejandro G Della Valle
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
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Chalmers BP, Goytizolo E, Mishu MD, Westrich GH. Manipulation under anaesthesia after primary total knee arthroplasty : minimal differences in intravenous sedation alone versus neuraxial anaesthesia. Bone Joint J 2021; 103-B:126-130. [PMID: 34053290 DOI: 10.1302/0301-620x.103b6.bjj-2020-1950.r1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Manipulation under anaesthesia (MUA) remains an effective intervention to address restricted range of motion (ROM) after total knee arthroplasty (TKA) and occurs in 2% to 3% of primary TKAs at our institution. Since there are few data on the outcomes of MUA with different anaesthetic methods, we sought to compare the outcomes of patients undergoing MUA with intravenous (IV) sedation and neuraxial anaesthesia. METHODS We identified 548 MUAs after primary TKA (136 IV sedation, 412 neuraxial anaesthesia plus IV sedation) from March 2016 to July 2019. The mean age of this cohort was 62 years (35 to 88) with a mean body mass index of 31 kg/m2 (18 to 49). The mean time from primary TKA to MUA was 10.2 weeks (6.2 to 24.3). Pre-MUA ROM was similar between groups; overall mean pre-MUA extension was 4.2° (p = 0.452) and mean pre-MUA flexion was 77° (p = 0.372). We compared orthopaedic complications, visual analogue scale (VAS) pain scores, length of stay (LOS), and immediate and three-month follow-up knee ROM between these groups. RESULTS Following MUA, patients with IV sedation had higher mean VAS pain scores of 5.2 (SD 1.8) compared to 4.1 (SD = 1.5) in the neuraxial group (p < 0.001). The mean LOS was shorter in patients that received IV sedation (9.5 hours (4 to 31)) compared to neuraxial anaesthesia (11.9 hours (4 to 51)) (p = 0.009), but an unexpected overnight stay was similar in each group (8.6%). Immediate-post MUA ROM was 1° to 121° in the IV sedation group and 0.9° to 123° in the neuraxial group (p = 0.313). Three-month follow-up ROM was 2° to 108° in the IV sedation group and 1.9° to 110° in the neuraxial anaesthesia group (p = 0.325) with a mean loss of 13° (ranging from 5° gain to 60° loss), in both groups by three months. No patients in either group sustained a complication. CONCLUSION IV sedation alone and neuraxial anaesthesia are both effective anaesthetic methods for MUA after primary TKA. Surgeons and anaesthetists should offer these anaesthetic techniques to match patient-specific needs as the orthopaedic outcomes are similar. Also, patients should be counselled that ROM following MUA may decrease over time. Cite this article: Bone Joint J 2021;103-B(6 Supple A):126-130.
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Affiliation(s)
- Brian P Chalmers
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - Enrique Goytizolo
- Department of Anesthesiology, Critical Care, and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Mithun D Mishu
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
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Patients undergoing manipulation after total knee arthroplasty are at higher risk of revision within 2 years. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:145-150. [PMID: 33760999 DOI: 10.1007/s00590-021-02943-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is a very common orthopedic procedure and stiffness is a common complication following TKA. There is extensive data regarding timing and success of Manipulation under anesthesia (MUA) for stiffness following TKA. However, Studies reporting outcome following MUA have often focused on the improvement in ROM and improvement in functional score with very few studies reporting on the revision risk. METHODS AND MATERIALS In this study we retrospectively reviewed PearlDiver insurance database and analyzed the characteristics of the patient undergoing MUA after TKA. We also analyzed the risk of revision at 2 years in a cohort of MUA patients who were matched to patients without MUA. RESULT Our study identified 9156 patients who underwent MUA within one year following TKA. MUA was slightly more common in females and risk of manipulation decreases with increasing age. Comparative analysis showed that at two years, patients in the matched MUA cohort (538 patients, 5.99%) were 2.9 times more likely to undergo revision TKA compared to the matched non MUA group (194, 2.16%)OR 2.88 (95% CI-2.44 to 3.41), P < 0.05 CONCLUSION: Retrospective database review showed that the risk of revision is higher in patients undergoing MUA after TKA and hence patient should be counselled about the possibility of revision in the future.
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Cregar WM, Khazi ZM, Lu Y, Forsythe B, Gerlinger TL. Lysis of Adhesion for Arthrofibrosis After Total Knee Arthroplasty Is Associated With Increased Risk of Subsequent Revision Total Knee Arthroplasty. J Arthroplasty 2021; 36:339-344.e1. [PMID: 32741708 DOI: 10.1016/j.arth.2020.07.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The aim of this study is to determine incidence of lysis of adhesion (LOA) for postoperative arthrofibrosis following primary total knee arthroplasty (TKA), patient factors associated with LOA, and impact of LOA on revision TKA. METHODS Patients who underwent primary TKA were identified in the Humana and Medicare databases. Patients who underwent LOA within 1 year after TKA were defined as the "LOA" cohort. Multiple binomial logistic regression analyses were performed to identify patient factors associated with undergoing LOA within 1 year after index TKA, and identify risk factors including LOA on risk for revision TKA within 2 years of index TKA. RESULTS In total, 58,538 and 48,336 patients underwent primary TKA in the Medicare and Humana databases, respectively. Incidence of LOA within 1 year after TKA was 0.56% in both databases. Age <75 years was a significant predictor of LOA in both databases (P < .05 for both). Incidence of revision TKA was significantly higher for the "LOA" cohort when compared to the "TKA Only" cohort in both databases (P < .0001 for both). LOA was the strongest predictor of revision TKA within 2 years after index TKA in both databases (P < .0001 for both). Additionally, age <65 years, male gender, obesity, fibromyalgia, smoking, alcohol abuse, and history of anxiety or depression were independently associated with increased odds of revision TKA within 2 years after index TKA (P < .05 for all). CONCLUSION Incidence of LOA after primary TKA is low, with younger age being the strongest predictor for requiring LOA. Patients who undergo LOA for arthrofibrosis within 1 year after primary TKA have a substantially high risk for subsequent early revision TKA. LEVEL OF EVIDENCE III, Retrospective Cohort Study.
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Affiliation(s)
- William M Cregar
- Department of Orthopedic Surgery, Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, IL
| | - Zain M Khazi
- Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Yining Lu
- Department of Orthopedic Surgery, Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, IL
| | - Brian Forsythe
- Department of Orthopedic Surgery, Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, IL
| | - Tad L Gerlinger
- Department of Orthopedic Surgery, Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, IL
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Brigati DP, Huddleston J, Lewallen D, Illgen R, Jaffri H, Ziegenhorn D, Weitzman DS, Bozic K. Manipulation Under Anesthesia After Total Knee: Who Still Requires a Revision Arthroplasty? J Arthroplasty 2020; 35:S348-S351. [PMID: 32247675 DOI: 10.1016/j.arth.2020.03.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Stiffness after total knee arthroplasty (TKA) is a multifactorial complication involving patient, implant, surgical technique, and rehabilitation, occasionally necessitating manipulation under anesthesia (MUA) or revision. Few modern databases contain sufficient longitudinal information of all factors. We characterized MUA after primary TKA and identified independent risk factors for revision TKA after MUA from the American Joint Replacement Registry. METHODS We retrospectively reviewed primary TKAs for American Joint Replacement Registry patients ≥65 years from January 1, 2012 to 31 March, 2019. We linked these to the Centers for Medicare and Medicaid Services database to identify MUA and revision TKA procedure codes. We compared groups with chi-squared testing, identifying independent risk factors for subsequent revision with binary logistic regression presented as odds ratios with 95% confidence intervals. RESULTS Of 664,604 primary TKAs, 3918 (0.6%) underwent MUA after a median of 2.0 ± 1.0 months. Revision surgery occurred in 131 (3.4%) MUA patients after a median of 9.0 months. Timing of MUA was not different between revision and no revision patients (P = .09). Patients undergoing MUA compared to no MUA were older (age 71.5 vs 70.7, P < .01), predominantly female (63.9% vs 61.2%, P < .01), current/former tobacco users (24.2% vs 13.3%, P < .01), with osteoarthritis diagnoses (98.0% vs 84.3%, P < .01). Independent risk factors for revision after MUA were male gender (1.56, 1.09-2.22). CONCLUSION The incidence of MUA after primary TKA is low (0.6%) in Medicare patients ≥65 years of age; 3.4% progress to revision after a median of 9 months. Being male was significantly associated with revision TKA after MUA.
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Affiliation(s)
- David P Brigati
- Texas Healthcare Bone & Joint Clinic, Fort Worth, Texas, USA
| | | | | | | | - Heena Jaffri
- American Academy Orthopaedic Surgeons, Rosemont, Illinois, USA
| | | | - Dena S Weitzman
- American Academy Orthopaedic Surgeons, Rosemont, Illinois, USA
| | - Kevin Bozic
- Dell Medical School at the University of Texas at Austin, Austin, Texas, USA
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