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Hannon CP, Goodman SM, Austin MS, Yates A, Guyatt G, Aggarwal VK, Baker JF, Bass P, Bekele DI, Dass D, Ghomrawi HMK, Jevsevar DS, Kwoh CK, Lajam CM, Meng CF, Moreland LW, Suleiman LI, Wolfstadt J, Bartosiak K, Bedard NA, Blevins JL, Cohen-Rosenblum A, Courtney PM, Fernandez-Ruiz R, Gausden EB, Ghosh N, King LK, Meara AS, Mehta B, Mirza R, Rana AJ, Sullivan N, Turgunbaev M, Wysham KD, Yip K, Yue L, Zywiel MG, Russell L, Turner AS, Singh JA. Erratum to "2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective" [The Journal of Arthroplasty 38 (2023) 2193-2201]. J Arthroplasty 2024; 39:851-852. [PMID: 38049357 DOI: 10.1016/j.arth.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Affiliation(s)
| | - Susan M Goodman
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | - C Kent Kwoh
- University of Arizona College of Medicine, Tucson
| | | | - Charis F Meng
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Linda I Suleiman
- Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Jesse Wolfstadt
- Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jason L Blevins
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Nilasha Ghosh
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | - Bella Mehta
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Katherine D Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle
| | - Kevin Yip
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Linda Yue
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Michael G Zywiel
- Schroeder Arthritis Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Linda Russell
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
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Roberts HJ, Hannon CP, Dilger OB, Bedard NA, Berry DJ, Abdel MP. New Ceramic Heads With Titanium Sleeves on Retained Femoral Components: Results of Over 500 Revision Total Hip Arthroplasties. J Arthroplasty 2024:S0883-5403(24)00070-6. [PMID: 38336305 DOI: 10.1016/j.arth.2024.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Ceramic heads are frequently combined with titanium sleeves in revision total hip arthroplasties (THAs), ostensibly to protect the ceramic head from existing damage to the retained trunnion. Although widely adopted, data on the performance and safety of this construct are minimal. The purpose of this study was to describe implant survivorships, radiographic results, and clinical outcomes of patients who underwent revision THA with a ceramic head and titanium sleeve on a retained femoral component. METHODS We identified 516 revision THAs with femoral component retention (328 acetabular-only revisions and 188 bearing surface exchanges) treated with a new ceramic head and titanium sleeve between 2000 and 2020. Mean age at revision was 64 years, 56% were women, and mean body mass index was 30. The indications for revision THA were adverse local tissue reaction (25%), acetabular loosening (24%), dislocation (17%), infection (5%), and other (29%). Kaplan-Meier survivorships were analyzed, radiographs reviewed, and Harris Hip Scores evaluated. Mean follow-up was 4 years (range, 2 to 10). RESULTS There were no reoperations or failures for ceramic head fracture, taper corrosion, or head/sleeve disengagement. The 10-year survivorship free of any re-revision was 85%. Indications for the 57 re-revisions included dislocation (33), infection (13), acetabular component loosening (7), periprosthetic fracture (2), psoas impingement (1), and sciatic nerve irritation (1). The 10-year survivorship free of any reoperation was 82%. There were an additional 14 reoperations. Radiographically, 1.9% had progressive femoral radiolucent lines, and 4.7% had progressive acetabular radiolucent lines. Mean Harris Hip Score was 81 at 2 years. CONCLUSIONS New ceramic heads with titanium sleeves in revision THAs with retained femoral components were durable and reliable with no cases of ceramic head fracture or taper complications at mean 4-year follow-up, including those revised for adverse local tissue reaction. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Charles P Hannon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Oliver B Dilger
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Sabatini FM, Cohen-Rosenblum A, Eason TB, Hannon CP, Mounce SD, Krueger CA, Gwathmey FW, Duncan ST, Landy DC. Incidence of Rapidly Progressive Osteoarthritis Following Intra-articular Hip Corticosteroid Injection: A Systematic Review and Meta-Analysis. Arthroplast Today 2023; 24:101242. [PMID: 37941925 PMCID: PMC10630590 DOI: 10.1016/j.artd.2023.101242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/05/2023] [Accepted: 09/14/2023] [Indexed: 11/10/2023] Open
Abstract
Background The American Academy of Orthopedic Surgery recommends intra-articular corticosteroid injections (CSIs) for managing hip osteoarthritis (OA) based on short-term, prospective studies. Recent retrospective studies have raised concerns that CSIs may lead to rapidly progressive OA (RPOA). We sought to systematically review the literature of CSIs for hip OA to estimate the incidence of RPOA. Methods MEDLINE, Embase, and Cochrane Library were searched to identify original research of hip OA patients receiving CSIs. Overall, 27 articles involving 5831 patients published from 1988 to 2022 were included. Study design, patient characteristics, CSI details, follow-up, and cases of RPOA were recorded. Studies were classified by their ability to detect RPOA based on follow-up. Random effects meta-analysis was used to calculate the incidence of RPOA for studies able to detect RPOA. Results The meta-analytic estimate of RPOA incidence was 6% (95% confidence interval, 3%-9%) based on 10 articles classified as able to detect RPOA. RPOA definitions varied from progression of OA within 6 months to the presence of destructive changes. These studies were subject to bias from excluding patients with missing post-CSI radiographs. The remaining 17 articles were classified as unable to detect RPOA, including all of the studies cited in the American Academy of Orthopedic Surgery recommendation. Conclusions The incidence of RPOA after CSIs remains unknown due to variation in definitions and follow-up. While RPOA following CSIs may be 6%, many cases are not severe, and this may reflect selection bias. Further research is needed to understand whether clinically significant RPOA is incident enough to limit CSI use.
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Affiliation(s)
- Franco M. Sabatini
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
| | | | - Travis B. Eason
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
| | - Charles P. Hannon
- Department of Orthopedic Surgery, Washington University, St. Louis, MO
| | - Samuel D. Mounce
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
| | - Chad A. Krueger
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, PA
| | - F. Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Stephen T. Duncan
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
| | - David C. Landy
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
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Parilla FW, Hannon CP, Pashos GE, Gresham KJ, Clohisy JC. Outcomes of Revision Total Hip Arthroplasty in Patients 60 Years and Younger. Iowa Orthop J 2023; 43:38-44. [PMID: 38213848 PMCID: PMC10777697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
Abstract
Background The annual volume of patients requiring revision total hip arthroplasty prior to age 60 is projected to increase considerably. Despite this, outcome data for revision THA in these younger patients remain limited. The purpose of this study was to define implant survivorship, identify risk factors for re-revision, and determine clinical outcomes of revision THA in patients aged ≤60 years. Methods We identified 191 revision THAs performed in patients aged ≤60 years. Minimum 4-year follow-up was obtained in 141 (73.8%) hips (mean 10.3 years [range, 4-20]). Mean age was 48 years (range, 20-60). Forty-five hips (32%) had previously been revised. Indications for index revision included aseptic loosening (28%), polyethylene wear (26%), dislocation (20%), and infection (14%). Outcome measures were Kaplan-Meier survival free from re-revision and patient-reported outcome scores (mHHS, UCLA). Results Survivorship free from re-revision for any cause was 78% [95% CI=70-85] at five years and 71% [62-78] at ten years. The most common indication for re-revision at both five and ten years was dislocation (12% [8-19], 16% [10-23]), followed by infection (6% [3-12], 10% [5-18]) and aseptic loosening (2% [1-7], 4% [1-11]). Mean scores were improved from baseline at six (mHHS +21.4, UCLA +0.9) and twelve years (mHHS +13.4, UCLA +0.5). Conclusion Revision THA in patients less than 60 years of age was associated with considerably lower rates of early loosening-related failure than historically reported. Recurrent dislocation and infection appear to remain challenges in this population. Despite improvements in survivorship from earlier studies, patient-reported functional improvements remained relatively unchanged. Level of Evidence: IV.
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Affiliation(s)
- Frank W. Parilla
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles P. Hannon
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gail E. Pashos
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Karla J. Gresham
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John C. Clohisy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Hannon CP, Goodman SM, Austin MS, Yates A, Guyatt G, Aggarwal VK, Baker JF, Bass P, Bekele DI, Dass D, Ghomrawi HMK, Jevsevar DS, Kwoh CK, Lajam CM, Meng CF, Moreland LW, Suleiman LI, Wolfstadt J, Bartosiak K, Bedard NA, Blevins JL, Cohen-Rosenblum A, Courtney PM, Fernandez-Ruiz R, Gausden EB, Ghosh N, King LK, Meara AS, Mehta B, Mirza R, Rana AJ, Sullivan N, Turgunbaev M, Wysham KD, Yip K, Yue L, Zywiel MG, Russell L, Turner AS, Singh JA. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. J Arthroplasty 2023; 38:2193-2201. [PMID: 37778918 DOI: 10.1016/j.arth.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/05/2023] [Accepted: 06/14/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVE To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
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Affiliation(s)
| | - Susan M Goodman
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | - C Kent Kwoh
- University of Arizona College of Medicine, Tucson
| | | | - Charis F Meng
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Linda I Suleiman
- Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Jesse Wolfstadt
- Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jason L Blevins
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Nilasha Ghosh
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | - Bella Mehta
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Katherine D Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle
| | - Kevin Yip
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Linda Yue
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Michael G Zywiel
- Schroeder Arthritis Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Linda Russell
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
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Hannon CP, Goodman SM, Austin MS, Yates A, Guyatt G, Aggarwal VK, Baker JF, Bass P, Bekele DI, Dass D, Ghomrawi HMK, Jevsevar DS, Kwoh CK, Lajam CM, Meng CF, Moreland LW, Suleiman LI, Wolfstadt J, Bartosiak K, Bedard NA, Blevins JL, Cohen-Rosenblum A, Courtney PM, Fernandez-Ruiz R, Gausden EB, Ghosh N, King LK, Meara AS, Mehta B, Mirza R, Rana AJ, Sullivan N, Turgunbaev M, Wysham KD, Yip K, Yue L, Zywiel MG, Russell L, Turner AS, Singh JA. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. Arthritis Rheumatol 2023; 75:1877-1888. [PMID: 37746897 DOI: 10.1002/art.42630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/05/2023] [Accepted: 06/14/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
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Affiliation(s)
| | - Susan M Goodman
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | - C Kent Kwoh
- University of Arizona College of Medicine, Tucson
| | | | - Charis F Meng
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Linda I Suleiman
- Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Jesse Wolfstadt
- Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jason L Blevins
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Nilasha Ghosh
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | - Bella Mehta
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Katherine D Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle
| | - Kevin Yip
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Linda Yue
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Michael G Zywiel
- Schroeder Arthritis Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Linda Russell
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
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7
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Hannon CP, Goodman SM, Austin MS, Yates A, Guyatt G, Aggarwal VK, Baker JF, Bass P, Bekele DI, Dass D, Ghomrawi HMK, Jevsevar DS, Kwoh CK, Lajam CM, Meng CF, Moreland LW, Suleiman LI, Wolfstadt J, Bartosiak K, Bedard NA, Blevins JL, Cohen-Rosenblum A, Courtney PM, Fernandez-Ruiz R, Gausden EB, Ghosh N, King LK, Meara AS, Mehta B, Mirza R, Rana AJ, Sullivan N, Turgunbaev M, Wysham KD, Yip K, Yue L, Zywiel MG, Russell L, Turner AS, Singh JA. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. Arthritis Care Res (Hoboken) 2023; 75:2227-2238. [PMID: 37743767 DOI: 10.1002/acr.25175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/05/2023] [Accepted: 06/14/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA). METHODS We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations. RESULTS The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality. CONCLUSION This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.
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Affiliation(s)
| | - Susan M Goodman
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Adolph Yates
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | | | | | | | | | | | - C Kent Kwoh
- University of Arizona College of Medicine, Tucson
| | | | - Charis F Meng
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Linda I Suleiman
- Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Jesse Wolfstadt
- Sinai Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jason L Blevins
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Nilasha Ghosh
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | - Bella Mehta
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Reza Mirza
- McMaster University, Hamilton, Ontario, Canada
| | | | | | | | - Katherine D Wysham
- VA Puget Sound Health Care System and University of Washington School of Medicine, Seattle
| | - Kevin Yip
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Linda Yue
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Michael G Zywiel
- Schroeder Arthritis Institute, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Linda Russell
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Jasvinder A Singh
- University of Alabama at Birmingham and Veterans Affairs Medical Center, Birmingham, Alabama
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Hannon CP, Salih R, Barrack RL, Nunley RM. Cementless Versus Cemented Total Knee Arthroplasty: Concise Midterm Results of a Prospective Randomized Controlled Trial. J Bone Joint Surg Am 2023; 105:1430-1434. [PMID: 37347823 DOI: 10.2106/jbjs.23.00161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND We previously reported the 2-year results of a prospective randomized controlled trial of cementless versus cemented total knee arthroplasty (TKA) implants of the same design. The purpose of the present study was to provide concise results at intermediate-term follow-up. METHODS The original study included 141 TKAs (76 performed without cement and 65 performed with cement). Since then, 8 patients died and 4 withdrew. Of the remaining 129 patients, 127 (98%) were available for analysis. Survivorship analysis was performed; Oxford Knee, Knee Society, and Forgotten Joint Scores were calculated; and radiographs reviewed. Mean follow-up was 6 years. RESULTS The survivorship free of any revision was 100% in both groups. There were no differences between the groups in any patient-reported functional outcome measure (p = 0.2 to 0.5). However, a higher percentage of patients in the cementless TKA group were either extremely or very satisfied with their overall function (p = 0.01). Radiographically, there was no evidence of implant loosening in either group. CONCLUSIONS At 6 years, there were no differences between cementless and cemented TKA implants of the same design in terms of survivorship, clinical, or radiographic outcomes. LEVEL OF EVIDENCE Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
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Wyles CC, Hannon CP, Viste A, Perry KI, Trousdale RT, Berry DJ, Abdel MP. Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty. JBJS Essent Surg Tech 2023; 13:e21.00003. [PMID: 38282724 PMCID: PMC10810589 DOI: 10.2106/jbjs.st.21.00003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
Background Removal of well-fixed femoral components during revision total hip arthroplasty (THA) can be difficult and time-consuming1, leading to numerous complications, such as femoral perforation, bone loss, and fracture. Extended trochanteric osteotomies (ETOs), which provide wide exposure and direct access to the femoral canal under controlled conditions, have become a popular method to circumvent these challenges. ETOs were popularized by Wagner (i.e., the anterior-based osteotomy), and later modified by Paprosky (i.e., the lateral-based osteotomy)2. Description The decision to utilize the laterally based Paprosky ETO versus the anteriorly based Wagner ETO is primarily based on surgeon preference, the location and type of in situ implants, and the osseous anatomy. Typically, a laterally based ETO is most facile in conjunction with a posterior approach and an anteriorly based ETO is most commonly paired with a lateral or anterolateral approach. Attention must be paid to maintaining vascularity to the osteotomy fragment, including minimizing stripping of the vastus lateralis from the osteotomy fragment and maintaining abductor attachments to the osteotomy fragment. When utilizing a laterally based ETO, the posterior border of the vastus lateralis must be carefully elevated to provide exposure for performance of the osteotomy. When an anteriorly based osteotomy is performed, the surgeon may instead extend the abductor tenotomy proximally with use of a longitudinal split of the vastus lateralis distally, which helps to keep the anterior and posterior sleeves of soft tissue in continuity. In either approach, dissection of the vastus lateralis involves managing several large vascular perforators. We prefer performing careful blunt dissection to identify the perforators and prophylactically controlling them, with ligation of large vessels and electrocautery of smaller vessels. Vascular clips are also available in case difficult-to-control bleeding is encountered. In general, an oscillating saw (with preference for a thin blade) is utilized to complete the posterior longitudinal limb of the ETO, extending approximately 12 to 16 cm distally from the tip of the greater trochanter. Although a 12 to 16-cm zone is required to maintain maximum vascularity to the osteotomized fragment, the osteotomy length must ultimately be determined by (1) the length of the femoral component to be removed; (2) the presence of distal bone ingrowth, ongrowth, or cement; and (3) the presence of distal hardware or stemmed knee components. A smaller oscillating saw is then utilized to complete the transverse limb at the previously identified distal extent. A high-speed pencil-tip burr is utilized to complete the corners of the osteotomy in a rounded configuration, and a combination of saws and pencil-tip burrs is utilized to create partial proximal and distal anterior longitudinal limbs of the osteotomy to the extent allowed by the soft-tissue attachments. The anterior longitudinal limb may be further weakened in a controlled fashion with use of serial drill holes. The anterior longitudinal limb then undergoes controlled fracture by placement of 2 to 4 broad straight osteotomes in the posterior longitudinal limb. These osteotomes are carefully levered anteriorly in unison with a gentle, steady force. After the ETO is completed, intramedullary prostheses, hardware, and cement are removed; the acetabulum is addressed as needed; and a final femoral stem is implanted, if appropriate. After completion of the osteotomy, the osteotomized fragment must be retracted gently, with care taken to avoid a fracture and maintain vascularity. To this end, debridement of the endosteum of the osteotomized fragment, including any cement removal, should be avoided until the end of the procedure, when the osteotomy is ready to be closed. Our preferred method for closure is to place 1 prophylactic cable 1 cm distal to the osteotomy, 1 to 2 cables along the diaphyseal segment of the osteotomy, and 1 Luque wire above the less trochanter. A Luque wire is our specific choice for the location above the lesser trochanter because it sits in the effective joint space; however, the use of Luque wires distal to the lesser trochanter is also acceptable. A strut allograft or locking plate can be utilized to reinforce the osteotomy in rare cases or to bridge interprosthetic stress risers. Trochanteric implants are typically avoided because of the low rate of clinically relevant trochanteric migration with this closure technique and because of the high rate of symptomatic implants with trochanteric claws or plates. Alternatives An alternative osteotomy of similar exposure is the transfemoral osteotomy. Additionally, a variety of non-extended trochanteric osteotomies, such as trochanteric slide osteotomies, offer more limited exposure. Rationale Femoral surgical exposure for revision THA can be aided by performing transfemoral osteotomies, but these provide less precise control of the separate proximal femoral osteotomized segment(s), and healing and fixation can be less reliable. Less invasive osteotomies such as non-extended trochanteric osteotomies typically do not provide adequate exposure in challenging cases for which ETO is being considered. Expected Outcomes ETOs have high union rates, and notable trochanteric migration is infrequent. The most common complications are fracture of the osteotomy fragment intraoperatively or postoperatively. Radiographic and clinical union is achieved in 98% of patients. The mean proximal trochanteric osteotomy fragment migration prior to union is 3 mm. ETO fragment migration of >1 cm occurs in just 7% of hips. Postoperative greater trochanter fractures occur in 9% of hips. The 10-year survivorship free of revision for aseptic femoral loosening, free of femoral or acetabular component removal or revision for any reason, and free of reoperation for any reason is 97%, 91%, and 82%, respectively3. Important Tips Attention should be paid to patient anatomy, deformity, surgical approach, and implant type when choosing to perform a laterally based Paprosky or anteriorly based Wagner ETO.Appropriate length of the posterior longitudinal limb of the ETO is approximately 12 to 16 cm distally from the tip of the greater trochanter.Attention must be paid to maintaining vascularity to the osteotomy fragment, including minimizing stripping of the vastus lateralis from the osteotomy fragment and maintaining abductor attachments to the osteotomy fragment.A high-speed pencil-tip burr should be utilized to complete the corners of the osteotomy in a rounded configuration in order to avoid stress risers.The anterior longitudinal limb is completed by controlled fracture of the remaining intervening segment in order to maintain vastus lateralis attachments and vascular supply to the osteotomy fragment.The ETO is closed with use of cerclage cables and/or double-stranded Luque wires, typically utilizing a total of 3 to 4 in order to obtain secure fixation without compromising local biology. Acronyms and Abbreviations MFT = modular fluted tapered.
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Affiliation(s)
- Cody C. Wyles
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Anthony Viste
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kevin I. Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Daniel J. Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Hannon CP, Abdel MP. Revision Total Hip Arthroplasty with a Modular Fluted Tapered Stem for a Periprosthetic Femoral Fracture. JBJS Essent Surg Tech 2023; 13:e22.00023. [PMID: 38282726 PMCID: PMC10810587 DOI: 10.2106/jbjs.st.22.00023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024] Open
Abstract
Background As the number of primary total hip arthroplasty procedures performed each year continues to rise, so too do the number of complications, including periprosthetic femoral fracture1-9. Vancouver B2 and B3 periprosthetic femoral fractures are difficult to treat because they require the surgeon to simultaneously manage a femoral fracture and gain new implant fixation. Fluted tapered stems have advanced the treatment of periprosthetic femoral fractures by providing immediate axial and rotational implant fixation distal to the fracture10-18. Modular fluted tapered stems provide the added practical advantage of allowing length and anteversion adjustment after implantation of the distal fixation portion of the stem. Description In this technique, a modified extended trochanteric osteotomy incorporating the fracture is utilized to gain access to the loose femoral implant and femoral diaphyseal canal. The femoral diaphyseal canal is then sequentially reamed in 1-mm increments. A fluted tapered stem with the appropriate length, diameter, and axial and rotational stability is inserted into the canal. A proximal body is then chosen that establishes the appropriate leg length, femoral offset, and version. The final proximal body is engaged into the fluted tapered stem. Finally, the fracture is fixed around the implant with a combination of cables or wires. Alternatives Historically, implants such as extensively porous coated stems were utilized to treat Vancouver B2 or B3 periprosthetic femoral fractures. Unfortunately, these implants were associated with high rates of failure and revision7,9. Rationale The introduction of a fluted tapered stem provided a more reliable implant that achieves immediate axial and rotational stability. In addition, utilizing a fluted tapered stem allowed for a more soft-tissue-preserving approach to these complex injuries, in turn allowing the fracture to be reduced around the implant proximally with cerclage cables and or wires. Modular fluted tapered stems provide the additional advantage of allowing the surgeon to modify leg length, offset, and femoral version, independently of the fluted tapered stem. As a result of these unique advantages, these stems were introduced several years ago for the treatment of Vancouver B2 or B3 periprosthetic femoral fractures. Expected Outcomes Contemporary series have demonstrated that the use of a modular fluted tapered stem leads to improved implant survivorship and clinical outcomes with lower complication rates for Vancouver B2 and B3 periprosthetic femoral fractures1,10-12,14-19. Important Tips Template both the fluted tapered stem and proximal body preoperatively. The proximal body should be templated at the ideal hip center of rotation that appropriately restores leg lengths and offset. Template the fluted tapered stem so that it provides appropriate isthmic fit and bypasses the most distal extent of the fracture by at least 2 cortical diameters.Utilize a modified extended trochanteric osteotomy for your exposure in order to facilitate visualization of the fracture and to provide direct access to the femoral canal.Place a prophylactic cable prior to preparing the femur for the implant in order to help prevent iatrogenic fracture.Place a trial stem and obtain intraoperative anteroposterior and lateral radiographs in order to assess the position of the implants and the risk of anterior cortical perforation.When placing the final implants, be sure the fluted tapered stem has both axial and rotational stability.Reduce and fix the fracture after the final implants are placed and the hip is reduced. Acronyms and Abbreviations AP = anteroposteriorMFT = modular fluted tapered (stem)ETO = extended trochanteric osteotomyTHA = total hip arthroplastyCT = computed tomographyPJI = periprosthetic joint infection.
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Affiliation(s)
- Charles P. Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Matthew P. Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Hollenberg AM, Yanik EL, Hannon CP, Calfee RP, O’Keefe RJ. Did the Physical and Mental Health of Orthopaedic Patients Change After the Onset of the COVID-19 Pandemic? Clin Orthop Relat Res 2023; 481:935-944. [PMID: 36696142 PMCID: PMC10097584 DOI: 10.1097/corr.0000000000002555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 12/20/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND The 2019 novel coronavirus (COVID-19) pandemic has been associated with poor mental health outcomes and widened health disparities in the United States. Given the inter-relationship between psychosocial factors and functional outcomes in orthopaedic surgery, it is important that we understand whether patients presenting for musculoskeletal care during the pandemic were associated with worse physical and mental health than before the pandemic's onset. QUESTIONS/PURPOSES (1) Did patients seen for an initial visit by an orthopaedic provider during the COVID-19 pandemic demonstrate worse physical function, pain interference, depression, and/or anxiety than patients seen before the pandemic, as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) instrument? (2) During the COVID-19 pandemic, did patients living in areas with high levels of social deprivation demonstrate worse patterns of physical function, pain interference, depression, or anxiety on initial presentation to an orthopaedic provider than patients living in areas with low levels of social deprivation, compared with prepandemic PROMIS scores? METHODS This was a retrospective, comparative study of new patient evaluations that occurred in the orthopaedic department at a large, urban tertiary care academic medical center. During the study period, PROMIS computer adaptive tests were routinely administered to patients at clinical visits. Between January 1, 2019, and December 31, 2019, we identified 26,989 new patients; we excluded 4% (1038 of 26,989) for being duplicates, 4% (1034 of 26,989) for having incomplete demographic data, 44% (11,925 of 26,989) for not having a nine-digit home ZIP Code recorded, and 5% (1332 of 26,989) for not completing all four PROMIS computer adaptive tests of interest. This left us with 11,660 patients in the "before COVID-19" cohort. Between January 1, 2021 and December 31, 2021, we identified 30,414 new patients; we excluded 5% (1554 of 30,414) for being duplicates, 4% (1142 of 30,414) for having incomplete demographic data, 41% (12,347 of 30,414) for not having a nine-digit home ZIP Code recorded, and 7% (2219 of 30,414) for not completing all four PROMIS computer adaptive tests of interest. This left us with 13,152 patients in the "during COVID-19" cohort. Nine-digit home ZIP Codes were used to determine patients' Area Deprivation Indexes, a neighborhood-level composite measure of social deprivation. To ensure that patients included in the study represented our overall patient population, we performed univariate analyses on available demographic and PROMIS data between patients included in the study and those excluded from the study, which revealed no differences (results not shown). In the before COVID-19 cohort, the mean age was 57 ± 16 years, 60% (7046 of 11,660) were women, 86% (10,079 of 11,660) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 47 ± 25. In the during COVID-19 cohort, the mean age was 57 ± 16 years, 61% (8051 of 13,152) were women, 86% (11,333 of 13,152) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 46 ± 25. The main outcome measures in this study were the PROMIS Physical Function ([PF], version 2.0), Pain Interference ([PI], version 1.1), Depression (version 1.0), and Anxiety (version 1.0). PROMIS scores follow a normal distribution with a mean t-score of 50 and a standard deviation of 10. Higher PROMIS PF scores indicate better self-reported physical capability, whereas higher PROMIS PI, Depression, and Anxiety scores indicate more difficulty managing pain, depression, and anxiety symptoms, respectively. Clinically meaningful differences in PROMIS scores between the cohorts were based on a minimum clinically important difference (MCID) threshold of 4 points. Multivariable linear regression models were created to determine whether presentation to an orthopaedic provider during the pandemic was associated with worse PROMIS scores than for patients who presented before the pandemic. Regression coefficients (ß) represent the estimated difference in PROMIS scores that would be expected for patients who presented during the pandemic compared with patients who presented before the pandemic, after adjusting for confounding variables. Regression coefficients were evaluated in the context of clinical importance and statistical significance. Regression coefficients equal to or greater than the MCID of 4 points were considered clinically important, whereas p values < 0.05 were considered statistically significant. RESULTS We found no clinically important differences in baseline physical and mental health PROMIS scores between new patients who presented to an orthopaedic provider before the COVID-19 pandemic and those who presented during the COVID-19 pandemic (PROMIS PF: ß -0.2 [95% confidence interval -0.43 to 0.03]; p = 0.09; PROMIS PI: ß 0.06 [95% CI -0.13 to 0.25]; p = 0.57; PROMIS Depression: ß 0.09 [95% CI -0.14 to 0.33]; p = 0.44; PROMIS Anxiety: ß 0.58 [95% CI 0.33 to 0.84]; p < 0.001). Although patients from areas with high levels of social deprivation had worse PROMIS scores than patients from areas with low levels of social deprivation, patients from areas with high levels of social deprivation demonstrated no clinically important differences in PROMIS scores when groups before and during the pandemic were compared (PROMIS PF: ß -0.23 [95% CI -0.80 to 0.33]; p = 0.42; PROMIS PI: ß 0.18 [95% CI -0.31 to 0.67]; p = 0.47; PROMIS Depression: ß 0.42 [95% CI -0.26 to 1.09]; p = 0.23; PROMIS Anxiety: ß 0.84 [95% CI 0.16 to 1.52]; p = 0.02). CONCLUSION Contrary to studies describing worse physical and mental health since the onset of the COVID-19 pandemic, we found no changes in the health status of orthopaedic patients on initial presentation to their provider. Although large-scale action to mitigate the effects of worsening physical or mental health of orthopaedic patients may not be needed at this time, orthopaedic providers should remain aware of the psychosocial needs of their patients and advocate on behalf of those who may benefit from intervention. Our study is limited in part to patients who had the self-agency to access specialty orthopaedic care, and therefore may underestimate the true changes in the physical or mental health status of all patients with musculoskeletal conditions. Future longitudinal studies evaluating the impact of specific COVID-19-related factors (for example, delays in medical care, social isolation, or financial loss) on orthopaedic outcomes may be helpful to prepare for future pandemics or natural disasters. LEVEL OF EVIDENCE Level II, prognostic study.
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Affiliation(s)
- Alex M. Hollenberg
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Elizabeth L. Yanik
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Charles P. Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Ryan P. Calfee
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Regis J. O’Keefe
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO, USA
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Booth MW, Riegler V, King JS, Barrack RL, Hannon CP. Patients' Perceptions of Remote Monitoring and App-based Rehabilitation Programs: A Comparison of Total Hip and Knee Arthroplasty. J Arthroplasty 2023:S0883-5403(23)00388-1. [PMID: 37088222 DOI: 10.1016/j.arth.2023.04.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Remote monitoring rehabilitation programs are new technologies growing in popularity for patients undergoing lower extremity total joint arthroplasty. The purpose of this study was to assess the patients' perceptions of these technologies. METHODS Patients who underwent total hip (THA), knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA) from September 2020 to February 2022 and participated in a clinical study utilizing remote monitoring and an app-based rehabilitation program were given a questionnaire three months postoperatively to assess their perceptions of these technologies. There were 166 patients who completed the survey (42 THA; 106 TKA; 18 UKA). RESULTS There were 92% of patients who found the technology easy to use. A majority of patients felt the technologies motivated them. The TKA/UKA patients felt more strongly that these technologies allowed the surgeon to monitor their recovery closely (81.9% v. 65.9%; P=0.009). There were 85% of THA patients and 94.5% of TKA/UKA patients recommended these technologies. The THA patients felt more strongly that digital rehabilitation could completely replace in-person physical therapy compared to TKA/UKA patients (85.4% v. 41.3%; P<0.001). A majority (83%) of patients recommended a combination of inpatient and technology-assisted rehabilitation (THA 90.2%; 84.4% TKA/UKA). CONCLUSIONS The THA and TKA/UKA patients found remote monitoring rehabilitation easy to use, increased motivation, and recommend it to other patients undergoing lower extremity arthroplasty. They recommend a combination of technology and in-person rehabilitation postoperatively. The THA patients felt these technologies could replace in-person rehabilitation programs.
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Affiliation(s)
- Matthew W Booth
- Department of Orthopedic Surgery, Washington University in St. Louis, 660S. Euclid Avenue, Campus Box 8233, St. Louis, MO 63110.
| | - Venessa Riegler
- Department of Orthopedic Surgery, Washington University in St. Louis, 660S. Euclid Avenue, Campus Box 8233, St. Louis, MO 63110.
| | - Jackie S King
- Department of Orthopedic Surgery, Washington University in St. Louis, 660S. Euclid Avenue, Campus Box 8233, St. Louis, MO 63110.
| | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University in St. Louis, 660S. Euclid Avenue, Campus Box 8233, St. Louis, MO 63110.
| | - Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, 660S. Euclid Avenue, Campus Box 8233, St. Louis, MO 63110.
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Lawrie CM, Hannon CP, Jo S, King J, Riegler V, Nunley RM, Barrack RL. Tourniquet use does not impact trajectory of total knee arthroplasty early recovery: A prospective, randomized controlled trial. J Arthroplasty 2023; 38:S7-S13. [PMID: 37019311 DOI: 10.1016/j.arth.2023.03.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 03/26/2023] [Accepted: 03/27/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND The impact of tourniquet use on recovery after total knee arthroplasty (TKA) remains controversial. The purpose of this prospective, single blinded, randomized controlled trial, was to investigate the effect of tourniquet use on early recovery after TKA using a smartphone app-based patient engagement platform (PEP) with a wrist-based activity monitor to obtain more robust data on early recovery. METHODS There were 107 patients undergoing primary TKA for osteoarthritis who were enrolled (54 tourniquet [TQ+]; 53 no tourniquet [TQ-]). All patients utilized a PEP and wrist-based activity sensor for two weeks preoperatively and 90 days postoperatively to collect Visual Analog Scale (VAS) pain scores and opioid consumption, as well as weekly Oxford Knee Score (OKS) and monthly Forgotten Joint Score (FJS). There was no difference in demographics between groups. Formal physical therapy assessments were performed preoperatively and 3 months postoperatively. Independent sample t-tests were used for continuous data and Chi-squared and Fisher's exact tests were used for discrete data. RESULTS Tourniquet use did not have a statistically significant impact on daily VAS pain or opioid consumption during the first 30 days postoperatively (P > 0.05). Tourniquet use did not have a significant impact on OKS or FJS at 30 or 90 days postoperatively (P> 0.05), or on performance of formal physical therapy testing at 3 months postoperatively (P> 0.05). CONCLUSIONS Using a digital technology to collect daily patient data, we found that tourniquet use has no clinically significant negative impact on pain and function in the first 90 days after primary TKA.
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Affiliation(s)
- Charles M Lawrie
- Baptist Health Orthopedic Care, Baptist Health South Florida, Miami, FL.
| | - Charles P Hannon
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Sally Jo
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jacqueline King
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Venessa Riegler
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Robert L Barrack
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
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Hannon CP, Fillingham YA, Gililland JM, Sporer SM, Casambre FD, Verity TJ, Woznica A, Nelson N, Hamilton WG, Della Valle CJ. A Systematic Review of the Efficacy and Safety of Ketamine in Total Joint Arthroplasty. J Arthroplasty 2023; 38:763-768.e2. [PMID: 36328104 DOI: 10.1016/j.arth.2022.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/20/2022] [Accepted: 10/24/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ketamine is administered intraoperatively to treat pain associated with primary total hip (THA) and knee arthroplasty (TKA). The purpose of this study was to evaluate the efficacy and safety of ketamine in primary THA and TKA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons (AAHKS), American Academy of Orthopaedic Surgeons (AAOS), Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management (ASRA). METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to 2020 on ketamine in THA and TKA. All included studies underwent qualitative assessment and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of ketamine. After a critical appraisal of 136 publications, 7 high-quality studies were included for analyses. RESULTS High-quality evidence demonstrates that intraoperative ketamine decreases postoperative opioid consumption. Four of 7 studies found that ketamine reduces postoperative pain. Intraoperative ketamine is not associated with an increase in adverse events and may reduce postoperative nausea and vomiting (relative risk [RR] 0.68; 95% CI 0.50-0.92). CONCLUSION High-quality evidence supports the use of ketamine intraoperatively in THA and TKA to reduce postoperative opioid consumption. Most studies found ketamine reduces postoperative pain, nausea, and vomiting. Moderate quality evidence supports the safety of ketamine, but it should be used cautiously in patients at risk for postoperative delirium, such as the elderly.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jeremy M Gililland
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah
| | - Scott M Sporer
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopedic Surgeons, Rosemont, Illinois
| | | | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
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Huddleston HP, Redondo ML, Cregar WM, Christian DR, Hannon CP, Yanke AB. The Effect of Aberrant Rotation on Radiographic Patellar Height Measurement Using Canton-Deschamps Index: A Cadaveric Analysis. J Knee Surg 2023; 36:254-260. [PMID: 34261156 DOI: 10.1055/s-0041-1731720] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The Caton-Deschamps Index (CDI) is a measurement used to evaluate patella alta based on true lateral radiographs; however, no prior study has investigated how altering the degree of radiograph aberrancy affects CDI measurement. The primary and secondary purpose of this study was to evaluate effects of rotational radiographic changes on patella height measurements and compare these findings to MRI measurements, respectively. Five cadaver knees (n = 5) were utilized in this study. True lateral radiographs were obtained for each specimen by using a fluoroscopic C-arm machine. The C-arm was then altered in two planes (axial and coronal) in both the clockwise and counterclockwise direction and radiographs were taken at 5, 10, and 15 degrees of error from the true lateral position. A CDI measurement of each specimen was performed based on sagittal magnetic resonance imaging (MRI) slices and compared with radiographic CDI measurements. Three orthopedic surgeons measured the CDI for each radiograph and MRI performed. Interrater reliability and changes in CDI were analyzed. Clinically significant difference in CDI was set to 0.1. Mean intraclass correlation coefficient was high (≥0.7) at true lateral and at all varying degrees of error. When performing a pairwise comparison of mean CDI from the true lateral position to increasing degrees of error, statistically significant differences were observed in the axial plane. The largest change in CDI measurements was seen with rotational malposition in the axial plane and counterclockwise direction. No statistically significant differences in mean CDI were observed in the coronal plane. The change in CDI from the true lateral position reached an absolute maximum of at least 0.1 in all four scenarios at each tested degree of error. This study found that aberrant radiographic rotation in the axial plane resulted in a significantly different mean CDI measurement when compared with true lateral radiographs. All degrees of error in both directions and in both planes could have a clinically significant effect on CDI (≥0.1). Our findings confirm the importance of a perfect true lateral radiograph when measuring patella height.
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Affiliation(s)
- Hailey P Huddleston
- Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Michael L Redondo
- Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - William M Cregar
- Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - David R Christian
- Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Charles P Hannon
- Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois
| | - Adam B Yanke
- Midwest Orthopedics at Rush, Rush University Medical Center, Chicago, Illinois
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Pereira DE, Kamara E, Krueger CA, Courtney PM, Austin MS, Rana A, Hannon CP. Prior Authorization in Total Joint Arthroplasty: A Survey of the American Association of Hip and Knee Surgeons Membership. J Arthroplasty 2023:S0883-5403(23)00042-6. [PMID: 36708936 DOI: 10.1016/j.arth.2023.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/13/2023] [Accepted: 01/19/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND This study surveyed the impact that prior authorization has on the practices of total joint arthroplasty (TJA) members of the American Association of Hip and Knee Surgeons (AAHKS). METHODS A 24-question survey was approved by the AAHKS Advocacy Committee and distributed to all 2,802 board-certified members of AAHKS. RESULTS There were 353 survey responses (13%). Ninety-five percent of surgeons noted a 5-year increase in prior authorization. A majority (71%) of practices employ at least 1 staff member to exclusively work on prior authorization. Average time spent on prior authorization was 15 h/wk (range, 1 to 125) and average number of claims peer week was 18 (range, 1 to 250). Surgeries (99%) were the most common denial. These were denied because nonoperative treatment had not been tried (71%) or had not been attempted for enough time (67%). Most (57%) prior authorization processes rarely/never changed the treatment provided. Most (56%) indicated that prior authorization rarely/never followed evidence-based guidelines. A majority (93%) expressed high administrative burden as well as negative clinical outcomes (87%) due to prior authorization including delays to access care (96%) at least sometimes. DISCUSSION Prior authorization has increased in the past 5 years resulting in high administrative burden. Prior authorizations were most common for TJA surgeries because certain nonoperative treatments were not attempted or not attempted for enough time. Surgeons indicated that prior authorization may be detrimental to high-value care and lead to potentially harmful delays in care without ultimately changing the management of the patient.
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Affiliation(s)
- Daniel E Pereira
- Department of Orthopaedic Surgery, Washington University, Saint Louis, Missouri
| | - Eli Kamara
- Orthopaedic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York
| | - Chad A Krueger
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew S Austin
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Adam Rana
- Maine Medical Partners Orthopedics and Sports Medicine, South Portland, Maine
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Washington University, Saint Louis, Missouri
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Matrka AK, Smith HM, Amundson AW, Duncan CM, Rueter MJ, Andrijasevic S, Hannon CP, Couch CG, Sanchez-Sotelo J, Trousdale RT, Abdel MP. Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies Project - Phase III Outcomes. J Arthroplasty 2022; 38:779-784. [PMID: 36403718 DOI: 10.1016/j.arth.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/27/2022] [Accepted: 11/10/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Our institution initiated the Orthopedic Surgery and Anesthesiology Surgical Improvement Strategies (OASIS) project in 2017 to improve the quality and efficiency for hip and knee arthroplasties. Phase III of this project aimed to: 1) increase same-day discharge (SDD) of primary total joint arthroplasties (TJAs) to 20%; 2) maintain or improve 30-day readmission rates; and 3) realize cost savings and revenue increases. METHODS All primary TJAs performed between 2021 and 2022 represented our study cohort, with those in 2019 (prepandemic) establishing the baseline cohort. A multidisciplinary team met weekly to track project tactics and metrics through the entire episode of care from preoperative surgical visit through 30 days postoperatively. RESULTS The SDD rate increased from 4% at baseline to 37%, with mean lengths of stay (LOS) decreasing from 1.5 to 0.9 days for all primary TJAs. The 30-day readmission rate decreased to 1.2 from 1.3%. Composite changes in surgical volume and cost reductions equaled $5 million. CONCLUSION Application of a multidisciplinary team with health systems engineering tools and methods allowed SDD to increase from 4 to 37% with a mean LOS <1 day, resulting in a $5 million incremental gain in profit at a major academic medical center. Importantly, patient safety was not compromised as 30-day readmission rates remained stable. LEVEL OF EVIDENCE III Therapeutic.
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Affiliation(s)
- Alexis K Matrka
- Mayo Clinic Department of Orthopedic Surgery, Rochester, Minnesota
| | - Hugh M Smith
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, Minnesota
| | - Adam W Amundson
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, Minnesota
| | - Christopher M Duncan
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, Minnesota
| | - Matthew J Rueter
- Mayo Clinic Practice Optimization and Acceleration, Rochester, Minnesota
| | - Sasa Andrijasevic
- Mayo Clinic Practice Optimization and Acceleration, Rochester, Minnesota
| | - Charles P Hannon
- Mayo Clinic Department of Orthopedic Surgery, Rochester, Minnesota
| | - Cory G Couch
- Mayo Clinic Department of Orthopedic Surgery, Rochester, Minnesota
| | | | | | - Matthew P Abdel
- Mayo Clinic Department of Orthopedic Surgery, Rochester, Minnesota
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18
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Schwabe MT, Hannon CP. The Evolution, Current Indications and Outcomes of Cementless Total Knee Arthroplasty. J Clin Med 2022; 11:jcm11226608. [PMID: 36431091 PMCID: PMC9693456 DOI: 10.3390/jcm11226608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/04/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022] Open
Abstract
Total knee arthroplasty (TKA) has been performed by orthopedic surgeons for decades, but the cementless TKA has only recently gained much interest in the world of arthroplasty. Initially, early designs had multiple complications, particularly with aseptic loosening due to osteolysis and micromotion. However, modifications have shown good outcomes and excellent survivorship. Over the last several decades, changes in implant designs as well as implant materials/coatings have helped with bone in growth and stability. Furthermore, surgeons have been performing TKA in younger and more obese patients as these populations have been increasing. Good results from the cementless TKA compared to cemented TKA may be a better option in these more challenging populations, as several studies have shown greater survivorship in patients that are younger and have a greater BMI. Additionally, a cementless TKA may be more cost effective, which remains a concern in today's healthcare environment. Overall, cemented and cementless TKA have great results in modern times and there is still a debate as to which implant is superior.
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19
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Casambre FD, Verity TJ, Woznica A, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Corticosteroids in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty 2022; 37:1898-1905.e7. [PMID: 36162922 DOI: 10.1016/j.arth.2022.03.084] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/09/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Corticosteroids are commonly used intraoperatively to treat pain and reduce opioid consumption and nausea associated with primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of corticosteroids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published before February 2020 on corticosteroids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of corticosteroids. RESULTS Critical appraisal of 1,581 publications revealed 23 studies regarded as the best available evidence for analysis. Intraoperative dexamethasone reduces postoperative pain, opioid consumption, and nausea and vomiting. Multiple doses lead to further reduction in pain, opioid consumption, nausea and vomiting. There is insufficient evidence on the risk of adverse events with perioperative dexamethasone in TJA. CONCLUSION Strong evidence supports the use of a single dose or multiple doses of intravenous dexamethasone to reduce postoperative pain, opioid consumption, nausea and vomiting after primary TJA. There is insufficient evidence on perioperative dexamethasone in primary TJA to determine the optimal dose, number of doses, or risk of postoperative adverse events.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Robert S Sterling
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
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Fillingham YA, Hannon CP, Kopp SL, Sershon RA, Stronach BM, Meneghini RM, Abdel MP, Griesemer ME, Austin MS, Casambre FD, Woznica A, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Regional Nerve Blocks in Total Hip Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2022; 37:1922-1927.e2. [PMID: 36162924 DOI: 10.1016/j.arth.2022.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/16/2022] [Accepted: 04/25/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Regional nerve blocks may be used as a component of a multimodal analgesic protocol to manage postoperative pain after primary total hip arthroplasty (THA). The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after THA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. METHODS We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published prior to March 24, 2020 on fascia iliaca, lumbar plexus, and quadratus lumborum blocks in primary THA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks. RESULTS An initial critical appraisal of 3,382 publications yielded 11 publications representing the best available evidence for an analysis. Fascia iliaca, lumbar plexus, and quadratus lumborum blocks demonstrate the ability to reduce postoperative pain and opioid consumption. Among the available comparisons, no difference was noted between a regional nerve block or local periarticular anesthetic infiltration regarding postoperative pain and opioid consumption. CONCLUSION Local periarticular anesthetic infiltration should be considered prior to a regional nerve block due to concerns over the safety and cost of regional nerve blocks. If a regional nerve block is used in primary THA, a fascia iliaca block is preferred over other blocks due to the differences in technical demands and risks associated with the alternative regional nerve blocks.
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Affiliation(s)
- Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Sandra L Kopp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Matthew S Austin
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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21
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Hannon CP, Fillingham YA, Spangehl MJ, Karas V, Kamath AF, Casambre FD, Verity TJ, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Periarticular Injection in Total Joint Arthroplasty: A Direct Meta-Analysis. J Arthroplasty 2022; 37:1928-1938.e9. [PMID: 36162925 DOI: 10.1016/j.arth.2022.03.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Periarticular injection (PAI) is administered intraoperatively to help reduce postoperative pain and opioid consumption after primary total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of PAI in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Medicine. METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published prior to March 2020 on PAI in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of PAI. RESULTS Three thousand six hundred and ninety nine publications were critically appraised to provide 60 studies regarded as the best available evidence for an analysis. The meta-analysis showed that intraoperative PAI reduces postoperative pain and opioid consumption. Adding ketorolac or a corticosteroid to a long-acting local anesthetic (eg, ropivacaine or bupivacaine) provides an additional benefit. There is no difference between liposomal bupivacaine and other nonliposomal long-acting local anesthetics. Morphine does not provide any additive benefit in postoperative pain and opioid consumption and may increase postoperative nausea and vomiting. There is insufficient evidence to draw conclusions on the use of epinephrine and clonidine. CONCLUSION Strong evidence supports the use of a PAI with a long-acting local anesthetic to reduce postoperative pain and opioid consumption. Adding a corticosteroid and/or ketorolac to a long-acting local anesthetic further reduces postoperative pain and may reduce opioid consumption. Morphine has no additive effect and there is insufficient evidence on epinephrine and clonidine.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | - Vasili Karas
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Tyler J Verity
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | | | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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22
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Fillingham YA, Hannon CP, Kopp SL, Austin MS, Sershon RA, Stronach BM, Meneghini RM, Abdel MP, Griesemer ME, Woznica A, Casambre FD, Nelson N, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Regional Nerve Blocks in Total Knee Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2022; 37:1906-1921.e2. [PMID: 36162923 DOI: 10.1016/j.arth.2022.03.078] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/14/2022] [Accepted: 03/26/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Regional nerve blocks are widely used in primary total knee arthroplasty (TKA) to reduce postoperative pain and opioid consumption. The purpose of our study was to evaluate the efficacy and safety of regional nerve blocks after TKA in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. METHODS We searched MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials for studies published before March 24, 2020 on femoral nerve block, adductor canal block, and infiltration between Popliteal Artery and Capsule of Knee in primary TKA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of the regional nerve blocks compared to a control, local peri-articular anesthetic infiltration (PAI), or between regional nerve blocks. RESULTS Critical appraisal of 1,673 publications yielded 56 publications representing the best available evidence for analysis. Femoral nerve and adductor canal blocks are effective at reducing postoperative pain and opioid consumption, but femoral nerve blocks are associated with quadriceps weakness. Use of a continuous compared to single shot adductor canal block can improve postoperative analgesia. No difference was noted between an adductor canal block or PAI regarding postoperative pain and opioid consumption, but the combination of both may be more effective. CONCLUSION Single shot adductor canal block or PAI should be used to reduce postoperative pain and opioid consumption following TKA. Use of a continuous adductor canal block or a combination of single shot adductor canal block and PAI may improve postoperative analgesia in patients with concern of poor postoperative pain control.
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Affiliation(s)
- Yale A Fillingham
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Sandra L Kopp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matthew S Austin
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Benjamin M Stronach
- Department of Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University Health, Indianapolis, Indiana
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Anne Woznica
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Francisco D Casambre
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | - Nicole Nelson
- Department of Clinical Quality and Value, American Academy of Orthopaedic Surgeons, Rosemont, Illinois
| | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Khan IA, Zaid MB, Gold PA, Austin MS, Parvizi J, Bedard NA, Jevsevar DS, Hannon CP, Fillingham YA. Making a Joint Decision Regarding the Timing of Surgery for Elective Arthroplasty Surgery After Being Infected With COVID-19: A Systematic Review. J Arthroplasty 2022; 37:2106-2113.e1. [PMID: 35533820 PMCID: PMC9074381 DOI: 10.1016/j.arth.2022.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/30/2022] [Accepted: 05/02/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The Coronavirus Disease 2019 (COVID-19) pandemic has caused a substantial number of patients to have their elective arthroplasty surgeries rescheduled. While it is established that patients with COVID-19 who are undergoing surgery have a significantly higher risk of experiencing postoperative complications and mortality, it is not well-known at what time after testing positive the risk of postoperative complications or mortality returns to normal. METHODS PubMed (MEDLINE), Excerpta Medica dataBASE, and professional society websites were systematically reviewed on March 7, 2022 to identify studies and guidelines on the optimal timeframe to reschedule patients for elective surgery after preoperatively testing positive for COVID-19. Outcomes included postoperative complications such as mortality, pneumonia, acute respiratory distress syndrome, septic shock, and pulmonary embolism. RESULTS A total of 14 studies and professional society guidelines met the inclusion criteria for this systematic review. Patients with asymptomatic COVID-19 should be rescheduled 4-8 weeks after testing positive (as long as they do not develop symptoms in the interim), patients with mild/moderate COVID-19 should be rescheduled 6-8 weeks after testing positive (with complete resolution of symptoms), and patients with severe/critical COVID-19 should be rescheduled at a minimum of 12 weeks after hospital discharge (with complete resolution of symptoms). CONCLUSIONS Given the negative association between preoperative COVID-19 and postoperative complications, patients should have elective arthroplasty surgery rescheduled at differing timeframes based on their symptoms. In addition, a multidisciplinary and patient-centered approach to rescheduling patients is recommended. Further study is needed to examine the impact of novel COVID-19 variants and vaccination on timeframes for rescheduling surgery.
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Affiliation(s)
- Irfan A. Khan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania,Address correspondence to: Irfan A. Khan, ATC, Rothman Orthopaedic Institute at Thomas Jefferson University, 925 Chestnut Street 5th Floor, Philadelphia, PA 19017
| | - Musa B. Zaid
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Peter A. Gold
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew S. Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - David S. Jevsevar
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Yale A. Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Hannon CP, Kruckeberg BM, Pagnano MW, Berry DJ, Hanssen AD, Abdel MP. Revision total knee arthroplasty for flexion instability : a concise follow-up of a previous report. Bone Joint J 2022; 104-B:1126-1131. [PMID: 36177638 DOI: 10.1302/0301-620x.104b10.bjj-2022-0358.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS We have previously reported the mid-term outcomes of revision total knee arthroplasty (TKA) for flexion instability. At a mean of four years, there were no re-revisions for instability. The aim of this study was to report the implant survivorship and clinical and radiological outcomes of the same cohort of of patients at a mean follow-up of ten years. METHODS The original publication included 60 revision TKAs in 60 patients which were undertaken between 2000 and 2010. The mean age of the patients at the time of revision TKA was 65 years, and 33 (55%) were female. Since that time, 21 patients died, leaving 39 patients (65%) available for analysis. The cumulative incidence of any re-revision with death as a competing risk was calculated. Knee Society Scores (KSSs) were also recorded, and updated radiographs were reviewed. RESULTS The cumulative incidence of any re-revision was 13% at a mean of ten years. At the most recent-follow-up, eight TKAs had been re-revised: three for recurrent flexion instability (two fully revised to varus-valgus constrained implants (VVCs), and one posterior-stabilized (PS) implant converted to VVC, one for global instability (PS to VVC), two for aseptic loosening of the femoral component, and two for periprosthetic joint infection). The ten-year cumulative incidence of any re-revision for instability was 7%. The median KSS improved significantly from 45 (interquartile range (IQR) 40 to 50) preoperatively to 70 (IQR 45 to 80) at a mean follow-up of ten years (p = 0.031). Radiologically, two patients, who had not undergone revision, had evidence of loosening (one tibial and one patellar). The remaining components were well fixed. CONCLUSION We found fair functional outcomes and implant survivorship at a mean of ten years after revision TKA for flexion instability with a PS implant. Recurrent instability and aseptic loosening were the most common indications for re-revision. Components with increased constraint, such as a VVC or hinged, should be used in these patients in order to reduce the risk of recurrent instability.Cite this article: Bone Joint J 2022;104-B(10):1126-1131.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arlen D Hanssen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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25
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Fillingham YA, Hannon CP, Kopp SL, Sershon RA, Stronach BM, Austin MS, Meneghini RM, Abdel MP, Griesemer ME, Hamilton WG, Della Valle CJ. Regional Nerve Blocks in Primary Total Hip Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37:1697-1700. [PMID: 35970571 DOI: 10.1016/j.arth.2022.02.121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/21/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Yale A Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | - Sandra L Kopp
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | | | | | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Matthew P Abdel
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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26
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Hannon CP, Fillingham YA, Mason JB, Sterling RS, Hamilton WG, Della Valle CJ. Corticosteroids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37:1684-1687. [PMID: 35970568 DOI: 10.1016/j.arth.2022.03.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/23/2022] [Accepted: 03/07/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | - Robert S Sterling
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Hannon CP, Fillingham YA, Hamilton WG, Della Valle CJ. Multimodal Analgesia and Anesthesia: Enabling Safe and Rapid Recovery for Total Joint Arthroplasty Patients. J Arthroplasty 2022; 37:1669-1670. [PMID: 35970566 DOI: 10.1016/j.arth.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Fillingham YA, Hannon CP, Austin MS, Kopp SL, Sershon RA, Stronach BM, Meneghini RM, Abdel MP, Griesemer ME, Hamilton WG, Della Valle CJ. Regional Nerve Blocks in Primary Total Knee Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2022; 37:1691-1696. [PMID: 35970570 DOI: 10.1016/j.arth.2022.02.120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 02/19/2022] [Indexed: 02/02/2023] Open
Affiliation(s)
- Yale A Fillingham
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Charles P Hannon
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Sandra L Kopp
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | | | | | | | - Matthew P Abdel
- Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO
| | | | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Terhune EB, Hannon CP, Burnett RA, Della Valle CJ. Preoperative Opioids and the Dose-Dependent Effect on Outcomes After Total Hip Arthroplasty. J Arthroplasty 2022; 37:S864-S870. [PMID: 34942347 DOI: 10.1016/j.arth.2021.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/18/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study is to identify the preoperative daily opioid dose associated with increased complications after primary total hip arthroplasty (THA). METHODS Primary THA patients in the Humana claims database (2007-2020) with an opioid prescription within 3 months prior to surgery were identified. Patients were stratified based on daily opioid dose: Tier 1, <5 milligram morphine equivalents (MME); Tier 2, 5-10 MME; Tier 3, 11-25 MME; Tier 4, 26-50 MME; Tier 5, >50 MME. Each tier was matched 1:1 to opioid-naïve patients. Emergency department (ED) visits, readmissions, and postoperative complications were compared. RESULTS In total, 67,719 patients using preoperative opioids were identified and matched. 17.0% of patients using preoperative opioids visited the ED within 90 days, compared to 13.3% of opioid-naïve patients (P < .001). About 9.5% of patients using preoperative opioids were readmitted within 90 days, compared to 7.4% of opioid-naïve patients (P < .001). When stratified by tier, opioid users in all tiers had higher risk of ED visits and readmission. Rates of superficial infection, periprosthetic joint infection, and dislocation were increased in patients taking preoperative opioids in Tiers 2 through 5. Patients in Tiers 3 through 5 had an increased risk of revision surgery. CONCLUSION Preoperative opioid use is associated with a dose-dependent increase in complications after THA. Just one 5 mg hydrocodone tablet daily leads to a significant increase in ED visits and readmission, while higher doses are associated with dislocation, superficial infection, periprosthetic joint infection, and revision surgery. Continued education regarding the harmful effects of opioids prescribed for the nonoperative treatment of osteoarthritis is still needed. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- E Bailey Terhune
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Washington University in St Louis, St Louis, MO
| | - Robert A Burnett
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Hannon CP, Sheehan KP, Duong SQ, Yuan BJ, Lewallen DG, Berry DJ, Abdel MP. Modular Fluted Tapered Stems for Periprosthetic Femoral Fractures: Excellent Results in 171 Cases. J Bone Joint Surg Am 2022; 104:1188-1196. [PMID: 35793797 DOI: 10.2106/jbjs.21.01168] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Modular fluted tapered (MFT) stems have advanced treatment of Vancouver B2 and B3 periprosthetic femoral fractures, but series to date have been limited with respect to cohort size and follow-up duration. The purpose of this study was to determine implant survivorship, radiographic results, complications, and clinical outcomes of Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems in a large series of patients. METHODS We identified 171 Vancouver B2 (109) and B3 (62) periprosthetic femoral fractures treated with an MFT stem between 2000 and 2018 using our institutional total joint registry. The mean age was 75 years, 50% were female, and the mean body mass index was 29 kg/m2. The median stem diameter was 18 mm and median stem length was 210 mm. The cumulative incidences of revision and reoperation with death as the competing risk were calculated, radiographs were reviewed, and clinical outcomes were evaluated using the Harris hip score (HHS). The mean follow-up was 5 years. RESULTS The 10-year cumulative incidence of any revision was 10%. There were 17 revisions, of which only 3 were for the distal fluted portion of the MFT stem. Revision indications included periprosthetic joint infection (PJI) (n = 6) and dislocation (n = 11). The 10-year cumulative incidence of any reoperation was 15%. In addition to the above 17 revisions, there were 7 reoperations for superficial wound complications (n = 4), Vancouver B1 periprosthetic femoral fracture (n = 1), vascular occlusion (n = 1), and acetabular cartilage degeneration requiring an acetabular component (n = 1). Radiographically, there was 1 fracture nonunion. All unrevised MFT stems were radiographically well fixed. Subsidence of ≥5 mm occurred in 11%, but all implants were stable at the most recent follow-up. The mean HHS was 75 at 2 years (n = 71). CONCLUSIONS In this large series of 171 Vancouver B2 and B3 periprosthetic femoral fractures treated with MFT stems, we found that such constructs were associated with a high rate of fracture healing and provided extremely reliable and durable implant fixation, with no revisions for aseptic loosening. Dislocation and PJI were the most common complications. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Lippold B, Tarkunde YR, Cheng AL, Hannon CP, Adelani MA, Calfee RP. Depression and Anxiety Screening Identifies Patients That may Benefit From Treatment Regardless of Existing Diagnoses. Arthroplast Today 2022; 15:215-219.e1. [PMID: 35774874 PMCID: PMC9237258 DOI: 10.1016/j.artd.2022.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 01/25/2022] [Indexed: 11/28/2022] Open
Abstract
Background This study investigated the utility of depression and anxiety symptom screening in patients scheduled for total knee arthroplasty to examine differences in active symptoms according to patients' mental health diagnoses and associated prescription medications. Material and methods This cross-sectional study analyzed 594 patients scheduled for total knee arthroplasty at a tertiary practice between June 2018 and December 2018. Patients completed Patient-Reported Outcomes Measurements Information System (PROMIS) Depression and Anxiety Computerized Adaptive Tests in clinic quantifying active symptoms. Mental health diagnoses and associated medications were extracted from health records. Statistical analysis assessed between-group differences in mean PROMIS scores and the prevalence of heightened depressive and anxiety symptoms. Results Multivariable linear regression modeling demonstrated that being diagnosed with depression without medication (β 7.1; P < .001) and with medication (β 8.6; P < .001) were each associated with higher PROMIS Depression scores. Similar modeling demonstrated that patients diagnosed with anxiety and prescribed an anxiolytic (β 8.4; P < .001) were associated with higher PROMIS Anxiety scores than undiagnosed patients. Eighty-six (15%) patients experienced heightened anxiety and/or depressive symptoms. Heightened depressive symptoms were more prevalent among those diagnosed with depression (19% without medication, 24% with antidepressant vs 5% undiagnosed: P < .001). Heightened anxiety symptoms were most prevalent among those diagnosed with anxiety and on anxiolytic medication (25% vs 7% diagnosed with anxiety without medication, 8% undiagnosed: P < .001). Conclusion One in seven arthroplasty patients screened reported heightened depressive and/or anxiety symptoms. Despite the majority of arthroplasty patients on antidepressants and anxiolytics having symptoms controlled, these patients remain at increased risk of heightened active symptoms.
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Affiliation(s)
- Brandon Lippold
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Yash R. Tarkunde
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Abby L. Cheng
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Charles P. Hannon
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Muyibat A. Adelani
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | - Ryan P. Calfee
- Department of Orthopedic Surgery, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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Hannon CP, Stuart MB, Abdel MP, Pagnano MW, Trousdale RT. Revision Total Knee Arthroplasty With a Rotating-Hinge Prosthesis Mated to a Well-Fixed Femoral Sleeve. J Arthroplasty 2022; 37:S270-S275. [PMID: 35227812 DOI: 10.1016/j.arth.2022.02.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Some knee systems have the unique capability to mate a new hinged femoral component to a well-fixed metaphyseal sleeve from a prior revision. We compared survivorship, radiographs, and clinical outcomes of a rotating-hinge total knee arthroplasty mated to a new metaphyseal sleeve vs a well-fixed sleeve. METHODS Sixty patients with an S-ROM Noiles (DePuy Synthes, Warsaw, IN) rotating-hinge total knee arthroplasty implanted from 1998 to 2019 were retrospectively reviewed. Nine patients (15%) had the femoral component mated to a well-fixed sleeve and 51 patients (85%) had a new sleeve. Mean age was 68 years, 68% were female, and mean body mass index was 33 kg/m2. The incidences of re-revision and reoperation were calculated, Knee Society Scores were measured, and radiographs were reviewed. Mean follow-up was 5 years. RESULTS There were 2 re-revisions (22%) in patients with a well-fixed sleeve: 1 for infection and 1 for aseptic loosening of the femur and tibia. There were no unique failures including the taper junction. Nine patients (18%) with a new sleeve were re-revised: 7 for infection and 2 for tibial aseptic loosening. The mean Knee Society Score for all patients improved from 39 to 73. Radiographically, all components were well fixed except for one loose femur in a patient with a new sleeve. CONCLUSION Mating an S-ROM femur to a well-fixed sleeve from a prior revision is a safe, simple, and durable option in the short term that prevents morbidity associated with removal of a well-fixed sleeve. No new modes of failure were observed. LEVEL OF EVIDENCE IV (retrospective), Therapeutic.
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Affiliation(s)
| | | | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Hannon CP, Kruckeberg BM, Lewallen DG, Berry DJ, Pagnano MW, Abdel MP. Treatment of Flexion Instability After Primary Total Knee Arthroplasty: Operative and Nonoperative Management of 218 Cases. J Arthroplasty 2022; 37:S333-S341. [PMID: 35218910 DOI: 10.1016/j.arth.2022.02.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND For patients with flexion instability, there is a paucity of literature on the effectiveness of nonoperative management, and series on revision TKAs are limited. The purpose of this study is to evaluate effectiveness and prognostic factors of nonoperative management of flexion instability, and report survivorship, clinical outcomes, and radiographic results after revision TKA for flexion instability. METHODS We identified 218 patients with flexion instability after primary TKA through our total joint registry between 1990 and 2019. Mean age was 66 years, 59% were women, and 58% had a cruciate-retaining (CR) implant. Initially, 152 patients (70%) were treated nonoperatively. First-time revision TKA was ultimately performed in 173 patients. Kaplan-Meier survivorship was calculated. Knee Society Scores and radiographs were reviewed. Mean follow-up was 6 years. RESULTS Of the 152 patients treated nonoperatively, 66% reported no improvement. Patients with a CR design (hazard ratio [HR] 3.3, P < .001), inflammatory arthritis (HR 1.6, P = .03), smokers (HR 2.1, P = .04), and patient-reported instability (HR 3.8, P < .001) or effusions (HR 3.5, P < .001) were more likely to undergo revision. Of the 173 revised, the 10-year survivorship free of any re-revision was 87% with recurrent flexion instability (7), global instability (3), and infection (3) being most common. Knee Society Scores improved from 50 to 65 (P = .14). At final follow-up, all implants were well-fixed. CONCLUSION In this large series of flexion instability after primary TKA, nonoperative management led to improvement in one third. Patients with a CR design or with patient-reported instability and/or effusions were most likely to undergo revision. Revision TKA demonstrated modest 10-year functional improvements and good survivorship. LEVEL OF EVIDENCE IV (retrospective), Therapeutic.
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Affiliation(s)
| | | | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN
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Austin MS, Ashley BS, Bedard NA, Bezwada HP, Hannon CP, Fillingham YA, Kolwadkar YV, Rees HW, Grosso MJ, Zeegen EN. What is the Level of Evidence Substantiating Commercial Payers' Coverage Policies for Total Joint Arthroplasty? J Arthroplasty 2021; 36:2665-2673.e8. [PMID: 33867209 DOI: 10.1016/j.arth.2021.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The prevalence of total joint arthroplasty (TJA) in the United States has drawn the attention of health care stakeholders. The payers have also used a variety of strategies to regulate the medical necessity of these procedures. The purpose of this study was to examine the level of evidence of the coverage policies being used by commercial payers in the United States. METHODS The references of the coverage policies of four commercial insurance companies were reviewed for type of document, level of evidence, applicability to a TJA population, and success of nonoperative treatment in patients with severe degenerative joint disease. RESULTS 282 documents were reviewed. 45.8% were primary journal articles, 14.2% were level I or II, 41.2% were applicable to patients who were candidates for TJA, and 9.9% discussed the success of nonoperative treatment in patients who would be candidates for TJA. CONCLUSION Most of the references cited by commercial payers are of a lower level of scientific evidence and not applicable to patients considered to be candidates for TJA. This is relatively uniform across the reviewed payers. The dearth of high-quality literature cited by commercial payers reflects the lack of evidence and difficulty in conducting high level studies on the outcomes of nonoperative versus operative treatment for patients with severe, symptomatic osteoarthritis. Patients, surgeons, and payers would all benefit from such studies and we encourage professional societies to strive toward that end through multicenter collaboration.
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Affiliation(s)
- Matthew S Austin
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Blair S Ashley
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Nicholas A Bedard
- Department of Orthopaedic Surgery, University of Iowa Hospitals & Clinics, Iowa City, IA
| | | | - Charles P Hannon
- Department of Orthopaedic Surgery, The Mayo Clinic, Ochester, MN
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Yogesh V Kolwadkar
- Department of Orthopaedic Surgery, VA Central California Health Care System, Fresno, CA
| | - Harold W Rees
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, IL
| | - Matthew J Grosso
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Connecticut Joint Replacement Institute, Hartford, CT
| | - Erik N Zeegen
- Department of Orthopaedic Surgery, University of California Los Angeles, Santa Monica, CA
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Abstract
Background. Hallux rigidus is a common pathology afflicting the foot, for which various joint salvage techniques have been described with a multitude of different implants. Recently, a synthetic cartilage implant composed of polyvinyl alcohol (PVA) received FDA premarket approval for the treatment of arthritis of the great toe. The purpose of this study was to (1) systematically review the clinical evidence supporting the use of a PVA implant in hallux rigidus and (2) determine the strength of the recommendation that can be made supporting the use of a PVA implant by evaluating the quality of evidence available. Methods. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Using the terms "cartiva OR polyvinyl alcohol OR synthetic cartilage OR hemiarthroplasty AND hallux rigidus OR great toe arthritis OR first toe arthritis" we searched the PubMed/Medline database. The quality of the included studies was evaluated using the American Academy of Orthopaedic Surgeons Clinical Practice Guideline and Systematic Review Methodology. Results. Seven studies met the inclusion criteria, 6 of these were derived from a single randomized controlled trial. A moderate recommendation can be given for the use of a PVA implant for hallux rigidus based on short-term outcomes. A limited recommendation can be given for the use of a PVA implant for hallux rigidus based on mid-term outcomes. Conclusion. There are limited studies available detailing the outcomes of a PVA implant for hallux rigidus; however, the results that are available demonstrate a high level of evidence.Levels of Evidence: Level I: Systematic review.
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Affiliation(s)
- Niall A Smyth
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida (NAS).,Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (CDM).,Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA (CPH).,Orthopaedic Specialty Institute, Orange, California (JRK).,Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida (AAA)
| | - Christopher D Murawski
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida (NAS).,Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (CDM).,Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA (CPH).,Orthopaedic Specialty Institute, Orange, California (JRK).,Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida (AAA)
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida (NAS).,Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (CDM).,Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA (CPH).,Orthopaedic Specialty Institute, Orange, California (JRK).,Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida (AAA)
| | - Jonathan R Kaplan
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida (NAS).,Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (CDM).,Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA (CPH).,Orthopaedic Specialty Institute, Orange, California (JRK).,Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida (AAA)
| | - Amiethab A Aiyer
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida (NAS).,Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (CDM).,Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA (CPH).,Orthopaedic Specialty Institute, Orange, California (JRK).,Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, Florida (AAA)
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Terhune EB, Hannon CP, Burnett RA, Della Valle CJ. Daily Dose of Preoperative Opioid Prescriptions Affects Outcomes After Total Knee Arthroplasty. J Arthroplasty 2021; 36:2302-2306. [PMID: 33526394 DOI: 10.1016/j.arth.2021.01.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/24/2020] [Accepted: 01/07/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The use of preoperative opioids is associated with complications after total knee arthroplasty (TKA), but the dosing threshold that constitutes this risk is not known. The purpose of this study was to identify the preoperative daily opioid dose associated with increased complications after primary TKA. METHODS Patients who underwent primary TKA in the Humana claims database (2007-2016) with an opioid prescription within 3 months before surgery were identified. All opioids prescribed within 3 months before TKA were converted to milligram morphine equivalents. Patients were stratified based on daily opioid dose: tier 1) <10, tier 2) 10-25, tier 3) 25-50, tier 4) >50 milligram morphine equivalents. Patients were matched to opioid-naïve patients by comorbidities, age, and gender. Emergency department (ED) visits, readmissions, and surgical complications were compared. RESULTS A total of 20,019 patients using preoperative opioids were identified and matched. ED visits and readmissions within 90 days were significantly higher in opioid users in all tiers (relative risk (RR) of ED visit: 1.25, 1.28, 1.34, and 1.25, respectively; readmission: 1.13, 1.17, 1.22, and 1.19, respectively). Rates of prosthetic joint infection were increased in opioid users in tiers 2, 3, and 4, and the risk increased in a dose-dependent manner (RR 1.37, 1.39, and 1.50, respectively). Patients in tier 4 had an increased risk of revision surgery (RR 1.44) at 2 years. CONCLUSION Preoperative opioid use is associated with a dose-dependent increase in postoperative complications after TKA. Just two 5mg hydrocodone tablets daily lead to increased ED visits and readmission. Higher doses are associated with an increased risk of prosthetic joint infection and revision surgery.
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Affiliation(s)
- E Bailey Terhune
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | | | - Robert A Burnett
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
| | - Craig J Della Valle
- Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL
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Burnett Iii RA, Yang J, Courtney PM, Terhune EB, Hannon CP, Della Valle CJ. Costs of unicompartmental compared with total knee arthroplasty : a matched cohort study over ten years. Bone Joint J 2021; 103-B:23-31. [PMID: 34053283 DOI: 10.1302/0301-620x.103b6.bjj-2020-2259.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to compare ten-year longitudinal healthcare costs and revision rates for patients undergoing unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). METHODS The Humana database was used to compare 2,383 patients undergoing UKA between 2007 and 2009, who were matched 1:1 from a cohort of 63,036 patients undergoing primary TKA based on age, sex, and Elixhauser Comorbidity Index. Medical and surgical complications were tracked longitudinally for one year following surgery. Rates of revision surgery and cumulative mean healthcare costs were recorded for this period of time and compared between the cohorts. RESULTS Patients undergoing TKA had significantly higher rates of manipulation under anaesthesia (3.9% vs 0.9%; p < 0.001), deep vein thrombosis (5.0% vs 3.1%; p < 0.001), pulmonary embolism (1.5% vs 0.8%; p = 0.001), and renal failure (4.2% vs 2.2%; p < 0.001). Revision rates, however, were significantly higher for UKA at five years (6.0% vs 4.2%; p = 0.007) and ten years postoperatively (6.5% vs 4.4%; p = 0.002). Longitudinal-related healthcare costs for patients undergoing TKA were greater than for those undergoing UKA at one year ($24,771 vs $22,071; p < 0.001) and five years following surgery ($26,549 vs $25,730; p < 0.001); however, the mean costs of TKA were comparable to UKA at ten years ($26,877 vs $26,891; p = 0.425). CONCLUSION Despite higher revision rates, patients undergoing UKA had lower mean healthcare costs than those undergoing TKA up to ten years following the procedure, at which time costs were comparable. In the era of value-based care, surgeons and policymakers should be aware of the costs involved with these procedures. UKA was associated with fewer complications at one year postoperatively but higher revision rates at five and ten years. While UKA was significantly less costly than TKA at one and five years, costs at ten years were comparable with a mean difference of only $14. Lowering the risk of revision surgery should be targeted as a source of cost savings for both UKA and TKA as the mean related healthcare costs were 2.5-fold higher in patients requiring revision surgery. Cite this article: Bone Joint J 2021;103-B(6 Supple A):23-31.
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Affiliation(s)
- Robert A Burnett Iii
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - JaeWon Yang
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - P Maxwell Courtney
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - E Bailey Terhune
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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Calkins TE, Hannon CP, Fillingham YA, Culvern CC, Berger RA, Della Valle CJ. Fixed-Bearing Medial Unicompartmental Knee Arthroplasty in Patients Younger Than 55 Years of Age at 4-19 Years of Follow-Up: A Concise Follow-Up of a Previous Report. J Arthroplasty 2021; 36:917-921. [PMID: 33051122 DOI: 10.1016/j.arth.2020.09.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/18/2020] [Accepted: 09/23/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Unicompartmental knee arthroplasty (UKA) is an effective alternative to total knee arthroplasty (TKA) in isolated unicompartmental disease; however, mid-term to long-term results in young patients are unknown. The purpose of this study is to determine the mid-term outcomes of fixed-bearing medial UKA in patients less than 55 years of age. METHODS Seventy-seven fixed-bearing medial UKAs in patients less than 55 years of age (mean 49.9, range 38-55) from a previously published report were retrospectively reviewed at a mean follow-up of 11.2 years (range 4.1-19.2). RESULTS Eleven knees were converted to TKA (14.3%) at 0.7-13.8 years postoperatively. The indications for revision included 7 for unexplained pain (9.1%), 2 for grade 4 arthritic progression (1 isolated lateral and 1 lateral and patellofemoral compartments; 2.6%), 1 for polyethylene wear (1.3%), and 1 for femoral component loosening (1.3%). Predicted survivorship free from component revision was 90.4% (95% confidence interval 86.9-93.9) at 10 years and 75.1% (95% confidence interval 66.2-84.0) at 19 years. The mean Knee Society Score improved from a mean of 51.9-88.6 points (P < .001). Of the 52 knees with 4-year minimum radiographs, 3 (5.8%) developed isolated grade 4 patellofemoral arthritis that was asymptomatic, and no knees had evidence of component loosening or osteolysis. CONCLUSION Fixed-bearing medial UKA is a durable option for young patients with unicompartmental arthritis, with good clinical outcomes at mid-term follow-up. Unexplained pain was the most common reason for revision to TKA.
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Affiliation(s)
- Tyler E Calkins
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee - Campbell Clinic, Memphis, TN
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Chris C Culvern
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Richard A Berger
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Hannon CP, Fillingham YA, Nam D, Courtney PM, Curtin BM, Vigdorchik JM, Buvanendran A, Hamilton WG, Della Valle CJ. Opioids in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2020; 35:2709-2714. [PMID: 32571594 DOI: 10.1016/j.arth.2020.05.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Affiliation(s)
- Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Denis Nam
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | | | | | | | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Hannon CP, Fillingham YA, Browne JA, Schemitsch EH, Mullen K, Casambre F, Visvabharathy V, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Gabapentinoids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2020; 35:2730-2738.e6. [PMID: 32586656 DOI: 10.1016/j.arth.2020.05.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Gabapentinoids are commonly used as an adjunct to traditional pain management strategies after total joint arthroplasty (TJA). The purpose of this study is to evaluate the efficacy and safety of gabapentinoids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. METHODS The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched for studies published prior to November 2018 on gabapentinoids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of gabapentinoids. RESULTS In total, 384 publications were critically appraised to provide 13 high-quality studies regarded as the best available evidence for analysis. In the perioperative period prior to discharge, pregabalin reduces postoperative opioid consumption, but gabapentinoids do not reduce postoperative pain. After discharge, gabapentin does not reduce postoperative pain or opioid consumption, but pregabalin reduces both postoperative pain and opioid consumption. CONCLUSION Moderate evidence supports the use of pregabalin in TJA to reduce postoperative pain and opioid consumption. Gabapentinoids should be used with caution, however, as they may lead to an increased risk of sedation and respiratory depression especially when combined with other central nervous system depressants such as opioids.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - James A Browne
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Emil H Schemitsch
- Department of Surgery, University of Western Ontario, London, Ontario, Canada
| | - Kyle Mullen
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Francisco Casambre
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Vidya Visvabharathy
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - William G Hamilton
- Department of Orthopaedic Surgery, Anderson Orthopedic Research Institute, Alexandria, VA
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Hannon CP, Fillingham YA, Nam D, Courtney PM, Curtin BM, Vigdorchik J, Mullen K, Casambre F, Riley C, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Opioids in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2020; 35:2759-2771.e13. [PMID: 32571589 DOI: 10.1016/j.arth.2020.05.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Opioids are frequently used to treat pain after total joint arthroplasty (TJA). The purpose of this study was to evaluate the efficacy and safety of opioids in primary TJA to support the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and the American Society of Regional Anesthesia and Pain Management. METHODS The MEDLINE, EMBASE, and Cochrane Central Register of controlled trials were searched for studies published before November 2018 on opioids in TJA. All included studies underwent qualitative and quantitative homogeneity testing followed by a systematic review and direct comparison meta-analysis to assess the efficacy and safety of opioids. RESULTS Preoperative opioid use leads to increased opioid consumption and complications after TJA along with a higher risk of chronic opioid use and inferior patient-reported outcomes. Scheduled opioids administered preemptively, intraoperatively, or postoperatively reduce the need for additional opioids for breakthrough pain. Prescribing fewer opioid pills after discharge is associated with equivalent functional outcomes and decreased opioid consumption. Tramadol reduces postoperative opioid consumption but increases the risk of postoperative nausea, vomiting, dry mouth, and dizziness. CONCLUSION Moderate evidence supports the use of opioids in TJA to reduce postoperative pain and opioid consumption. Opioids should be used cautiously as they may increase the risk of complications, such as respiratory depression and sedation, especially if combined with other central nervous system depressants or used in the elderly.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Denis Nam
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - P Maxwell Courtney
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | | | - Jonathan Vigdorchik
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Kyle Mullen
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Francisco Casambre
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Connor Riley
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Fillingham YA, Hannon CP, Erens GA, Hamilton WG, Della Valle CJ. Acetaminophen in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2020; 35:2697-2699. [PMID: 32571591 DOI: 10.1016/j.arth.2020.05.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Affiliation(s)
- Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Greg A Erens
- Department of Orthopaedic Surgery, Emory University, Atlanta, GA
| | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Fillingham YA, Hannon CP, Roberts KC, Hamilton WG, Della Valle CJ. Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: The Clinical Practice Guidelines of the American Association of Hip and Knee Surgeons, American Society of Regional Anesthesia and Pain Medicine, American Academy of Orthopaedic Surgeons, Hip Society, and Knee Society. J Arthroplasty 2020; 35:2704-2708. [PMID: 32571593 DOI: 10.1016/j.arth.2020.05.043] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Affiliation(s)
- Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Karl C Roberts
- Department of Orthopaedic Surgery, Michigan State University, Grand Rapids, MI
| | | | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Fillingham YA, Hannon CP, Roberts KC, Mullen K, Casambre F, Riley C, Hamilton WG, Della Valle CJ. The Efficacy and Safety of Nonsteroidal Anti-Inflammatory Drugs in Total Joint Arthroplasty: Systematic Review and Direct Meta-Analysis. J Arthroplasty 2020; 35:2739-2758. [PMID: 32690428 DOI: 10.1016/j.arth.2020.05.035] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) have become widely used to manage perioperative pain following total joint arthroplasty (TJA). The purpose of our study is to evaluate the efficacy and safety of NSAIDs in support of the combined clinical practice guidelines of the American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Hip Society, Knee Society, and American Society of Regional Anesthesia and Pain Management. METHODS Databases including MEDLINE, EMBASE, and the Cochrane Central Registry of Controlled Trials were searched for studies published prior to November 2018 on NSAIDs in TJA. Studies included after a systematic review evaluated through direct comparisons and/or meta-analysis, including qualitative and quantitative heterogeneity testing, to evaluate effectiveness and safety of NSAIDs. RESULTS After critical appraisal of 2921 publications, 25 articles represented the best available evidence for inclusion in the analysis. Oral selective cyclooxygenase (COX)-2 and non-selective NSAIDs and intravenous ketorolac safely reduce postoperative pain and opioid consumption during the hospitalization for primary TJA. Administration of an oral selective COX-2 NSAID reduced postoperative opioid consumption after discharge from TKA. CONCLUSION Strong evidence supports the use of an oral selective COX-2 or non-selective NSAID and intravenous ketorolac as adjunctive medications to manage postoperative pain during the hospitalization for TJA. Although no safety concerns were observed, prescribers need to remain vigilant when prescribing NSAIDs.
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Affiliation(s)
- Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Karl C Roberts
- Department of Orthopaedic Surgery, Michigan State University, Grand Rapids, MI
| | - Kyle Mullen
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Francisco Casambre
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | - Connor Riley
- Department of Research, Quality, and Scientific Affairs, American Academy of Orthopaedic Surgeons, Rosemont, IL
| | | | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Hannon CP, Cotter EJ, Cooper HJ, Deirmengian CA, Rodriguez JA, Urban RM, Paprosky WG, Jacobs JJ. Adverse Local Tissue Reaction due to Mechanically Assisted Crevice Corrosion Presenting as Late Instability Following Metal-on-Polyethylene Total Hip Arthroplasty. J Arthroplasty 2020; 35:2666-2670. [PMID: 32389403 DOI: 10.1016/j.arth.2020.04.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/17/2020] [Accepted: 04/09/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Mechanically assisted crevice corrosion (MACC) at modular junctions can cause a spectrum of adverse local tissue reactions (ALTRs) in patients who have undergone total hip arthroplasty (THA). The purpose of this study is to describe the presentation, treatments, and related complications of a cohort of patients presenting with late instability following metal-on-polyethylene THA due to underlying MACC and ALTR. METHODS This multicenter retrospective case series presents 17 patients (12 women, mean age 62.6, range 42-73) presenting with late instability secondary to ALTR and MACC. All patients had a metal (Cobalt Chrome)-on-polyethylene bearing surface. Patients experienced a mean 2.7 dislocations (range 1-6) at mean 4.3 years (range 0.4-17.0) following their index surgery. Serum metal levels (n = 12) demonstrated a greater elevation of cobalt (mean 6.9, range 0.13-20.88 ng/mL) than chromium (mean 1.9, range 0.13-3.23 ng/mL). RESULTS Patients were revised for instability at a mean of 6.8 years (range 2.1-19.4) following their index surgery. ALTR was encountered in every case and the modular head-neck junction demonstrated visible corrosion. An exchange of the CoCr head to a ceramic head with a titanium sleeve and placement of a constrained liner was performed for a majority of patients (n = 15, 88.2%). Five patients (29.4%) had complications postoperatively including peroneal palsy (n = 2), periprosthetic joint infection (n = 2), and ALTR recurrence (n = 1). CONCLUSION Recurrent instability in the setting of otherwise well-positioned THA components and without another obvious cause should raise concern for ALTR as a potential underlying etiology.
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Affiliation(s)
- Charles P Hannon
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Eric J Cotter
- Department of Orthopaedic Surgery, University of Wisconsin-Madison, Madison, WI
| | - H John Cooper
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY
| | - Carl A Deirmengian
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Jose A Rodriguez
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Robert M Urban
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Wayne G Paprosky
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Joshua J Jacobs
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Kunze KN, Beletsky A, Hannon CP, LaPrade RF, Yanke AB, Cole BJ, Forsythe B, Chahla J. Return to Work and Sport After Proximal Tibial Osteotomy and the Effects of Opening Versus Closing Wedge Techniques on Adverse Outcomes: A Systematic Review and Meta-analysis. Am J Sports Med 2020; 48:2295-2304. [PMID: 31774691 DOI: 10.1177/0363546519881638] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although many studies have reported successful functional outcomes after proximal tibial osteotomy (PTO), a paucity of literature has sought to quantify outcomes and current rates of return to sport (RTS) and return to work (RTW) after PTO. PURPOSE To (1) determine current rates of RTS and RTW after PTO and (2) quantify the incidence of complications and conversion to total knee arthroplasty (TKA) after PTO for all patients as well as those undergoing opening and closing wedge PTO. STUDY DESIGN Systematic review and meta-analysis; Level of evidence, 4. METHODS The Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (2008-2019), EMBASE (2008-2019), and MEDLINE (2008-2019) databases were queried. Data pertaining to article information, patient demographics, surgical techniques, rates of complication and conversion to TKA, patient-reported outcome scores, RTS, and RTW were extracted. Data were synthesized, and a random effects meta-analysis of proportions using continuity correction methods was performed to determine the proportion of patients receiving opening and closing wedge PTO who experienced adverse events. RESULTS The review and meta-analysis included 33 studies involving 1914 patients who underwent PTO with a weighted mean ± SD age of 50.3 ± 9.9 years and body mass index of 26.9 ± 2.3 kg/m2. The pooled RTS and RTW rates were 75.7% (range, 55%-100%) in 814 patients and 80.8% (range, 41%-100%) in 505 patients, respectively. The pooled TKA rate was 12.5% (range, 0%-35.7%) at a mean of 70.6 months and the pooled complication rate was 11.1% (range, 0%-28.6%). The overall random pooled summary estimate of the proportion of patients who underwent opening wedge PTO and subsequently converted to TKA was 2.0% (95% CI, 1.0%-4.0%; I2 = 63.65) at a mean of 43.4 ± 31.9 months and who experienced a complication was 6.0% (95% CI, 3.0%-9.0%; I2 = 87.10%). For closing wedge PTO, the proportion of patients who converted to TKA was 5.0% (95% CI, 1.0%-9.0%; I2 = 93.1%) and experienced a complication was 2.0% (95% CI, 1.0%-3.0%; I2 = 90.0%). Only 53.8% of studies that referenced RTS provided postoperative RTS rates, and 80% of studies that referenced RTW provided RTW rates. Only 1 study defined RTS criteria, no studies defined RTW criteria, and 31 different outcome measures were reported across all studies. CONCLUSION Patients undergoing PTO for osteoarthritis, cartilage defects, and symptomatic malalignment of the knee experience high rates of RTS and RTW. These patients also experience low rates of complications and conversion to TKA, regardless of opening or closing wedge technique. Significant heterogeneity exists with regard to criteria used to define RTS and RTW and patient-reported outcome measures used to assess clinical and functional improvements after PTO.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Alexander Beletsky
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Charles P Hannon
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Adam B Yanke
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian Forsythe
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Nahhas CR, Hannon CP, Yang J, Gerlinger TL, Nam D, Della Valle CJ. Education Increases Disposal of Unused Opioids After Total Joint Arthroplasty: A Cluster-Randomized Controlled Trial. J Bone Joint Surg Am 2020; 102:953-960. [PMID: 32251139 DOI: 10.2106/jbjs.19.01166] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Unused opioid pills are a danger to patients and their loved ones as they may be diverted for abuse or misuse. The purpose of this study was to determine the baseline rate of proper disposal of unused opioids among patients undergoing total joint arthroplasty and to determine how education impacts disposal rates. METHODS In this study, 563 patients undergoing primary total joint arthroplasty (183 patients undergoing total hip arthroplasty, 293 patients undergoing total knee arthroplasty, and 87 patients undergoing unicompartmental knee arthroplasty) were cluster-randomized to groups that received no education, educational pamphlets, or educational pamphlets plus text messages. Patients were randomized by education class and were blinded to participation to avoid behavioral modifications. Patients were surveyed at 6 weeks postoperatively to determine if they disposed of their unused opioid pills using a U.S. Food and Drug Administration-recommended method, which was the primary outcome. Assuming a 15% difference in opioid disposal rates as clinically relevant, power analysis determined that 76 patients with unused opioids were required per group (228 total). An as-treated analysis was conducted with the Fisher exact text and analysis of variance with alpha = 0.05. RESULTS A total of 539 patients (95.7%) completed the survey, and 342 patients (63.5%) had unused opioid pills at 6 weeks postoperatively: 89 patients in the no education group, 128 patients in the pamphlet group, and 125 patients in the pamphlet and text message group. Of these 342 patients, 9.0% of patients in the no education group, 32.8% of patients in the pamphlet group, and 38.4% of patients in the pamphlet and text message group properly disposed of their unused opioids (p = 0.001 for each educational intervention compared with no education). Unused opioid pills were kept by 82.0% of patients in the no education group, 64.1% of patients in the pamphlet group, and 54.4% of patients in the pamphlet and text message group (p < 0.001 for the no education group compared with either educational strategy group). Patients who underwent total hip arthroplasty were more likely to properly dispose of their unused opioids compared with those who underwent total knee arthroplasty (odds ratio, 2.1; p = 0.005). There were no demographic differences between groups, including inpatient opioid use, refills, and preoperative opioid use, other than sex (41.5% male patients in the no education group, 55.0% male patients in the pamphlet group, and 37.4% male patients in the pamphlet and text message group; p = 0.001), suggesting appropriate randomization. CONCLUSIONS The rate of opioid disposal is very low after total joint arthroplasty. Education on opioid disposal more than triples opioid disposal rates compared with no education. To help to prevent diversion of unused opioid pills, all patients who undergo total joint arthroplasty should be educated on the proper disposal of unused opioids.
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Affiliation(s)
- Cindy R Nahhas
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Abstract
The COVID-19 global pandemic presents a challenge to orthopaedic education. Around the world, including in the United States, elective surgeries are being deferred and orthopaedic residents and fellows are being asked to make drastic changes to their daily routines. In the midst of these changes are unique opportunities for resident/fellow growth and development. Educational tools in the form of web-based learning, surgical simulators, and basic competency tests may serve an important role. Challenges are inevitable, but appropriate preparation may help programs ensure continued resident growth, development, and well-being while maintaining high-quality patient care.
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Affiliation(s)
- Monica Kogan
- From the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL (Dr. Kogan, Dr. Hannon, and Dr. Nolte), and the Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Klein)
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Hurley ET, Shimozono Y, Hannon CP, Smyth NA, Murawski CD, Kennedy JG. Platelet-Rich Plasma Versus Corticosteroids for Plantar Fasciitis: A Systematic Review of Randomized Controlled Trials. Orthop J Sports Med 2020; 8:2325967120915704. [PMID: 32426407 PMCID: PMC7222276 DOI: 10.1177/2325967120915704] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 10/17/2019] [Indexed: 01/08/2023] Open
Abstract
Background: Plantar fasciitis is the most common cause of plantar heel pain. Several
recent randomized control trials (RCTs) have been published comparing the
use of platelet-rich plasma (PRP) and corticosteroids (CSs) for the
treatment of plantar fasciitis. Purpose: To perform a systematic review of RCTs to compare whether PRP or CS
injections result in decreased pain levels and improved patient outcomes in
the treatment of plantar fasciitis. Study Design: Systematic review; Level of evidence, 1. Methods: Medline, EMBASE, and the Cochrane Library were screened according to the
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)
guidelines to identify RCTs comparing PRP and CS injections for plantar
fasciitis. The visual analog scale (VAS) pain scores and the American
Orthopaedic Foot and Ankle Society (AOFAS) scores were compared between
groups at 1, 1.5, 3, 6, and 12 months, where possible. Statistical analysis
was performed using RevMan, and P < .05 was considered
to be statistically significant. Results: A total of 9 RCTs were identified comparing 239 patients with PRP with 240
patients with CS injections. At the follow-up time points, including 1-1.5,
3, 6, and 12 months, there were statistically significant differences in VAS
scores in favor of PRP (P = .004, P <
.00001, P < .00001, and P < .00001,
respectively). At 1 and 3 months, there was no difference in AOFAS scores
(P = .76 and P = .35, respectively).
However, at 6 and 12 months, there was a difference in AOFAS scores in favor
of PRP (P < .00001 and P < .00001,
respectively). Conclusion: In patients with chronic plantar fasciitis, the current clinical evidence
suggests that PRP may lead to a greater improvement in pain and functional
outcome over CS injections.
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Affiliation(s)
- Eoghan T Hurley
- NYU Langone Health, New York, New York, USA.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Yoshiharu Shimozono
- NYU Langone Health, New York, New York, USA.,Kyoto University Graduate School of Medicine, Department of Orthopaedic Surgery, Kyoto, Japan
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50
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Nahhas CR, Fuller BC, Hannon CP, Gerlinger TL, Nam D, Della Valle CJ. Which Nonsurgical Treatments Do Patients Believe Are Most Effective for Hip and Knee Arthritis? J Am Acad Orthop Surg Glob Res Rev 2020; 4:e2000046. [PMID: 33970578 PMCID: PMC7434029 DOI: 10.5435/jaaosglobal-d-20-00046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/28/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND The purpose of this study was to determine which nonsurgical treatments patients believe are most effective for managing pain secondary to hip and knee arthritis. METHODS Five hundred sixty-five consecutive patients were administered an anonymous questionnaire developed in consultation with a center with expertise in survey design. Statistical analyses included Student t-test, Fisher Exact, Wilcoxon Rank-Sum test, and generalized cost-effectiveness analysis. RESULTS Four hundred thirty-six patients completed the questionnaire (response rate 77.2%). Opioids (52 of 118; 44.1%), prescription nonsteroidal anti-inflammatory drugs (NSAIDs) (67 of 200; 33.5%), and corticosteroid injections (87 of 260; 33.5%) were reported as most effective. Stem cell and platelet-rich plasma injections were selected by three of 12 (25.0%) and three of 15 patients (19.5%), respectively, and physical therapy (PT) by 50 of 257 patients (19.5%). Twenty-five percent of respondents received opioids, commonly prescribed by primary care providers (48.2%) and orthopaedic surgeons (39.5%). Opioid use correlated with lower patient-reported effectiveness of PT, NSAIDs, and corticosteroid injections (P < 0.05). The highest cost-effectiveness ratios were NSAIDs, opioids, and acetaminophen (2.2, 3.7, 4.0, and 5.4, respectively). The lowest cost-effectiveness ratios were stem cell injections, platelet-rich plasma injections, and PT (1966.7, 520.8, and 138.6, respectively). CONCLUSIONS The nonsurgical treatments that are reported by patients to be most effective are oftentimes the least expensive.
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Affiliation(s)
- Cindy R Nahhas
- From the Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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