Cementless tapered wedge stems in patients undergoing primary total hip arthroplasty with Dorr C bone-are complication risks increased?

Background

The use of cementless femoral stems in patients undergoing primary total hip arthroplasty (THA) with Dorr C bone remains controversial for fear of fracture or subsidence. Purpose of this multicenter study was to compare clinical outcomes and complications of THA using a tapered femoral prosthesis in patients with Dorr C bone versus Dorr A/B bone.

Methods

A total of 1,030 patients underwent primary THA with a tapered wedge femoral stem at a minimum one year follow up. Forty-eight patients with Dorr C bone (mean age 68.7 years) were compared with a matched cohort of patients with Dorr A/B bone (mean age 69.9 years). Mean follow-up was approximately 4 years in both cohorts. There were no differences in sex, age, body mass index (BMI), Harris Hip Score (HHS), complications, and radiographic outcomes including subsidence and aseptic loosening were evaluated.

Results

Postoperative HHSs were a mean of 82 points in the Dorr C cohort compared to 84 points in the Door A/B cohort (P=0.2653). There was no significant difference in complication or revision rates for any reason (P=0.23). Mean subsidence for the Dorr C and Dorr A/B was 1.4 and 1.2 mm, respectively (P=0.5164), and there was no aseptic loosening of the femoral component found in either group.

Conclusions

Current generation tapered wedge cementless femoral stems provide stable fixation for patients with Dorr C bone quality without increased complications with respect to fracture or subsidence and can be considered an alternative to cemented stems in patients with compromised bone quality.

Comparing Outcomes for Female Total Knee Arthroplasty Patients Under Global Budget Revenue

Maryland implemented the all-payer, rater-setting Global Budget Revenue (GBR) payment model in 2014 to reduce cost and improve quality. This study assessed the effect of GBR on total knee arthroplasty (TKA) outcomes by sex. Specifically, the authors assessed (1) demographics and (2) outcomes of males and females undergoing TKA before and after GBR implementation. The Maryland State Inpatient Database was queried from 2011 to 2016. There were 71,066 TKAs (male, n=25,413; female, n=45,634). For continuous and categorical variables, t testing and chi-square analyses were used, respectively. Difference-in-difference analyses using multiple regression compared changes in sex from the pre-GBR period (2011-2013) with the post-GBR period (2014-2016). The female proportion decreased (-1.9%; P=.040). Proportionally more TKA patients were Hispanic and Asian, from high-income areas, using Medicare and Medicaid, and morbidly obese (all P<.001). The mean length of stay (LOS), charges, and costs were decreased after GBR implementation (all P<.001). More patients were discharged routine and had fewer readmissions (both P<.001). There were fewer complications, including deep venous thromboses/pulmonary emboli, urinary tract infections, and blood transfusions (all P<.001). The difference-in-difference analyses suggested more females were discharged with home health care and had longer LOS than did males (both P<.001). The GBR appears to meet its main objective of cost reduction and improvements in quality of care. However, the proportion of females receiving TKA decreased, and their LOS did not improve as much as that of males. As other states consider global budgets, more research is needed to ensure this all-payer, rate-setting, capitated system does not cause decreased access to care. [Orthopedics. 2021;44(2):e266-e273.].

Obesity in Total Hip Arthroplasty: Demographic Disparities and Outcome Incongruities

Introduction

As morbid obesity disproportionately affects minorities and those of lower socioeconomic status, body mass index (BMI) restrictions on total hip arthroplasty (THA) may harm populations already facing disparities in care. Therefore, this study analyzed demographics and outcomes in morbidly obese primary THA patients.

Methods

The National Inpatient Sample was queried for THAs performed between 2009 and 2016. Of 2,676,086 patients identified, 453,250 had a BMI over 25 kg/m². Patients were stratified by BMI into overweight (BMI=25.0-29.9 kg/m²), non-morbidly obese (BMI=30.0-40.0 kg/m²), and morbidly obese (BMI>40.1 kg/m²). Patient demographics (age, sex, race, insurance, income, and Charlson Comorbidity Index) and outcomes (length of stay [LOS], mortality, disposition, complications, charges, and costs) were assessed. Categorical and continuous data were analyzed with chi-square analyses and one-way analyses of variance, respectively.

Results

The number of overweight, non-morbidly obese, and morbidly obese patients increased by 299.0%, 109.3%, and 90.9%, respectively, between 2009 and 2016 (p<0.001). Morbidly obese patients were younger than non-morbidly obese and overweight patients (p<0.001) and had a higher proportion of females (p<0.001) and black patients (p<0.001). Morbidly obese patients most frequently used Medicaid and private insurance (p<0.001). Morbidly obese patients demonstrated a longer LOS, a higher mortality rate, a lower rate of home discharges and the most complications (all, p<0.001). 

Conclusion

These results reflect the worsening obesity epidemic and may be useful in counseling preoperative weight loss to morbidly obese patients to reduce mortality and complications.

Diclofenac Versus Ketorolac for Pain Control After Primary Total Joint Arthroplasty: A Comparative Analysis

Introduction As total hip arthroplasty (THA) and total knee arthroplasty (TKA) transition to outpatient settings, appropriate pain management remains a challenge. Nonsteroidal anti-inflammatory drugs (NSAIDs) may subvert the need for postoperative opioids. This study evaluated: 1) total opioid consumption; 2) postoperative pain intensity; 3) discharge destination; 4) length of stay (LOS); and 5) THA and TKA patients' satisfaction in receiving adjunctive intravenous (IV) diclofenac or ketorolac. Methods In this retrospective cohort study, patients scheduled to undergo primary THA or TKA by a single surgeon between March 2017 and April 2018 were identified. Patients were stratified based on the receipt of IV diclofenac (THA: n = 25; TKA: n = 51) or IV ketorolac (THA: n = 28; TKA: n = 32) in addition to the standard pain management regimen. Student's t-testing and Chi-square were used to analyze continuous and categorical variables, respectively. Results TKA diclofenac patients had lower opioid consumption 12 hours postoperatively (p: 0.037). TKA patients in the diclofenac cohort were discharged to home less often (p: 0.025). Both diclofenac cohorts had greater patient satisfaction than the ketorolac cohorts (p: <0.05). There was no significant difference between groups in postoperative pain intensity at 24 or 48 hours or in the length of stay (p: >0.05 for all). Conclusion This study demonstrated that both TKA and THA patients treated with IV diclofenac had no difference in postoperative pain intensity while THA patients had no difference in opioid consumption relative to those treated with IV ketorolac. Further comparison of IV NSAIDs with other IV pain medications may provide broader insight into the ideal management for postoperative pain for this widening patient population.

Use of home neuromuscular electrical stimulation in the first 6 weeks improves function and reduces pain after primary total knee arthroplasty: a matched comparison

Background

The use of neuromuscular electrical stimulation (NMES) after total knee arthroplasty (TKA) has been demonstrated to facilitate quadriceps muscle recovery and to reduce pain. However, to our knowledge, this therapeutic modality has not been directly tested in patients who receive muscle stimulators for home use immediately after surgery. Therefore, the purpose of this study was to assess the effect of NMES use at home in addition to standard therapy program in patients after primary TKA surgery, and to compare the early functional results to a matching group of post TKA patients who did not receive home NMES units.

Methods

A total of 41 patients scheduled for a primary TKA during April 1^st, 2017 to January 31^st, 2018 were identified as being eligible for the study. There were 15 patients deemed ineligible to be part of the study, resulting in 26 patients who were fitted either 1 week before or within 1 week of surgery a home NMES device. The device was controlled by a smart phone. Patients were asked to use the NMES device daily for 20 minutes, 3 times a day, for 6 weeks after surgery. As their ability to activate their quadriceps muscle improved, patients were encouraged to increase their exercise regimens. The NMES patients were compared to a matched cohort of 26 patients who had a TKA performed between June 1^st, 2015 and July 31^st, 2016, but did not receive home an NMES device. Comparative outcomes included: timed up and go (TUG) test, single limb stance (SLS) time, time to ascend and descend one flight of stairs, quadriceps lag, active and passive range of motion (ROM), 2-minute walking distance, and pain rating on a visual analog scale (VAS). A P value of 0.05 was set as the threshold for statistical significance for the matched comparison.

Results

Patients in the home NMES had significantly better scores for quadriceps lag (P<0.001), TUG (P<0.001), time to ascend and descend one flight of stairs (P=0.001), SLS time (P<0.001). They also experienced significantly lower resting pain (P<0.001) and lower worst reported pain scores (P<0.001) compared to the control cohort. Additionally, there were a higher percentage of patients in the control cohort that could not use stairs reciprocally compared to the home NMES group (53.85% vs. 23.08%). Furthermore, passive range of motion for flexion was statistically better in the home NMES group (P=0.037).

Conclusions

This matched comparison of primary TKA patients demonstrated significant pain reductions both at rest and lower worst reported pain scores and improved function with use of the home-based NMES units for the sub-acute phase of recovery. Patients walked longer distances safely as shown by improvements in TUG, quadriceps lag, and single limb support time. Larger proportions of patients in home NMES group were able to negotiate stairs reciprocally and faster than the matched control group. These findings may have important economic and functional implications for the post-operative care of TKA patient.

What Influences How Patients Rate Their Hospital After Total Knee Arthroplasty?

INTRODUCTION

There is increasing pressure from Centers for Medicare and Medicaid Services (CMS) to report quality measures for all hospitalizations. These quality measures are determined based on results from satisfaction surveys, such as Press Ganey® (PG) (Press Ganey® Performance Solutions, Wakefield, Massachusetts). Included in this particular survey element are questions regarding staff, including nurses and doctors, as well as items such as pain control. The results of these surveys will dictate the amount doctors are compensated for their services. Therefore, this study was undertaken to evaluate the effect of treating orthopaedists and nurses, as well as pain control, on PG surveys in patients who underwent total knee arthroplasty (TKA). Specifically, we aimed to ascertain the effect of these factors on how post-TKA patients perceive: 1) their orthopaedist, and 2) their overall surgical experience.

MATERIALS AND METHODS

We queried the Press Ganey® Database for all patients who underwent a TKA at our institution between November 2009 and January 2015. A weighted mean of question domains was utilized since each had multiple questions. In order to assess if pain management influences orthopaedist perception, a correlation analysis was performed between pain control and perception. In order to assess the influence of pain management on surgical experience, we performed a correlation analysis between pain control and overall hospital rating. A multiple regression analysis was performed using the hospital rating as the dependent variable to determine the most influential factors on surgical experience.

RESULTS

Our analysis demonstrated a significantly positive correlation between patient perception of their pain control and their orthopaedist. There was a significant positive correlation between patient's perception of their pain control and their overall surgical experience. Multiple regression analysis using overall surgical experience as the dependent variable demonstrated a significant positive influence of perception of nurses and orthopaedists. Pain management positively influenced surgical experience; however, this was not significant.

CONCLUSIONS

We found that perception of pain control in post-TKA patients affects perception of the treating orthopaedists, as well as their overall surgical experience. In addition, perception of orthopaedists and nurses both outweigh perception of pain control on overall surgical experience, with nurses being the most important. Orthopaedists should focus on staff education-particularly nurses-and educate them in order to optimize results on PG surveys and, ultimately, improve patient satisfaction. Further studies should correlate current standardized scoring systems and questionnaires for TKA with PG surveys in order to recognize gaps that need to be bridged to improve post-TKA patient satisfaction.

Total knee arthroplasty in patients over 80 years of age

We conducted this study to review the clinical and radiographic outcomes of patients 80 years of age or older who underwent total knee arthroplasty (TKA). We identified clinical results in 60 patients (66 knees) who had a mean age of 84 years (range, 80 to 95 years) and who underwent TKA. These were compared with a non-age-matched group of 63 patients (66 knees) who had a mean age of 69 years (range, 60 to 79 years). Four patients were lost to follow-up. After a mean 43-month follow-up (range, 24 to 117 months), Knee Society pain and function scores for the study group improved from 53 points (range, 25 to 70 points) and 53 points (range, 40 to 70 points), respectively, to 94 points (range, 75 to 100 points) and 87 points (range, 45 to 100 points). There were no implant failures, 2 surgical complications, and 13 medical complications. In the matching group, there were four surgical complications (two required revision) and two medical complications. There were no radiographic failures or progressive radiolucencies. Although the incidence of medical complications in the perioperative period may be higher, TKA is a safe and effective treatment for refractory joint pain in patients over 80 years of age.