Introduction. The use of intraoperative liposomal bupivacaine (LB) peri-articular injection has been highly debated for total knee arthroplasty (TKA). We evaluated the effect of an institutional-wide discontinuation of intraoperative LB on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. Material and Methods. Between July 1, 2019 and November 30, 2019, an institutional
Introduction. As total knee arthroplasty incidence in the United States continues to increase, health care entities are looking to reform
Introduction. Emergency department (ED) visits following primary total knee arthroplasty (TKA) can lead to poor patient satisfaction, potentially unnecessary readmissions, and greater overall healthcare costs. Reasons for post-operative ED visits are often entirely medical in nature and can be independent of the recent operation. Several strategies have been developed to help reduce ED visits. However, one major factor that can play a critical role in addressing potentially avoidable visits is provider and patient education. A major factor that can play a crucial role in addressing potentially avoidable visits is provider and patient education. It follows that a thorough understanding of which patients are visiting the ED and why can help in avoiding the visits. Therefore, the purpose of this study was to investigate: 1) causes and 2) patient-related factors (demographics and comorbidities) associated with ED visits following primary TKA. Methods. A national private payer database was queried for primary TKAs performed between 2007 and 2016 using the International Classification of Disease, ninth revision (ICD-9) procedural code 81.54. ED visits were identified using Current Procedural Terminology (CPT) codes 99281 to 99285. Patients with 90-day ED visits were in the study group (n=28,044) whereas those without 90-day ED visits served as controls (n=82,289). Causes for ED visits were divided into cardiopulmonary, gastrointestinal, renal, thromboembolic, leg pain, or wound-related. Patient demographics and risk factors assessed included age, gender, and body mass index (BMI) as well as several comorbidities (Table 1). Pearson's chi-square tests were performed to compare patient demographics and comorbidities between the cohorts. In order to adjust for potential confounders, multivariate binomial logistic regression analysis was performed to further evaluate the associations between patient factors and 90-day ED visits. A p-value less than 0.01 was considered statistically significant. Results. The most common reasons for ED visits were cardiopulmonary (51.30%), leg/back pain (46.20%), and gastrointestinal (31.60%) reasons. There was a greater proportion of women in the ED visit cohort compared to controls (p<0.0001; Table 1) and comorbidities (p<0.0001). Multivariate analysis revealed that patients with a history of COPD (odds ratio [OR] 1.48, p<0.001), depression (OR 1.42, p<0.0001), arrhythmias (OR: 1.38, p<0.0001), AIDS (O: 1.32, p<0.0001), and iron deficiency anemia (OR 1.28, p<0.0001), were at an increased risk of visting the ED within 90 days following primary TKA (Table 2). Conclusion. This analysis of over 100,000 patients identified that the most common reasons for ED visits are primarily medical in nature, and are not necessarily directly related to the recent operation. These findings should help guide pre-operative education and manage post-operative expectations to help limit potentially avoidable ED visits. Additionally, the data from this study can lend to
A 5 year review of factors instigating malpractice claims and likely to result in a payout. Possible lessons for the future. Background. During 2002-2007 over 300,000 patients underwent knee arthroplasty (KA) in England and Wales, from which 204 cases of litigation were processed costing in excess of £5million. The complications associated with primary KA are well documented, however those instigating litigation in the UK are not known. This study assessed trends in litigation over the past 5 years identifying instigating factors and success rates to highlight areas for further improvement in patient information and surgical management. Methods. Data from the NHS Litigation Authority on claims following KA unrelated to trauma between 2002 and 2007 were obtained and analysed. Results. 246 claims were made, 171 (70%) were settled of which 81 (47%) resulted in a successful claim. The total cost to the NHS was £5,257,228. The number of claims has increased from 26 in 2002 to 67 in 2007, while the rate of successful claims decreased from 58% to 9%. The three most common instigating factors were ongoing pain(24%), operator error(23%) and infection(10%). The factors with greatest successful claims were operator error(80%), vascular injuries(75%), failure of post-operative care(55%). Conclusion. Litigation claims following KA are increasing, although there rate of success is decreasing. Operator error, vascular injuries and failure of post-operative care are predictors of a successful claim. However failure to consent adequately, adhere to
Introduction. In November 2017, the Center for Medicare and Medicaid Services (CMS) finalized the 2018 Medicare Outpatient Prospective Payment System rule that removed total knee arthroplasty (TKA) procedures from the Medicare inpatient-only (IPO) list of procedures. This action had significant and unexpected consequences. For several years, CMS has utilized a rule called the “Two-Midnight Rule” to define outpatient status for all procedures not on the IPO list. CMS made TKA subject to the “Two-Midnight Rule” in conjunction with the decision to move TKA off the IPO list. According to the “Two-Midnight Rule,” a hospital admission should be expected to span at least two midnights in order to be covered as an inpatient procedure. If it can be reliably expected that the patient will not require at least two midnights in the hospital, the “Two-Midnight Rule” suggests that the patient is considered an outpatient and is therefore subject to outpatient payment
The tibial component of total knee arthroplasty can either be an all-polyethylene (AP) implant or a metal-backed (MB) implant. This study aims to compare the five-year functional outcomes of AP tibial components to MB components in patients aged over 70 years. Secondary aims are to compare quality of life, implant survivorship, and cost-effectiveness. A group of 130 patients who had received an AP tibial component were matched for demographic factors of age, BMI, American Society of Anesthesiologists (ASA) grade, sex, and preoperative Knee Society Score (KSS) to create a comparison group of 130 patients who received a MB tibial component. Functional outcome was assessed prospectively by KSS, quality of life by 12-Item Short-Form Health Survey questionnaire (SF-12), and range of motion (ROM), and implant survivorships were compared. The SF six-dimension (6D) was used to calculate the incremental cost effectiveness ratio (ICER) for AP compared to MB tibial components using quality-adjusted life year methodology.Aims
Methods
Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up. This prospective study included 16 patients undergoing robotic arm-assisted revision of UKA to TKA versus 35 matched patients receiving robotic arm-assisted primary TKA. In all study patients, the following data were recorded: operating time, polyethylene liner size, change in haemoglobin concentration (g/dl), length of inpatient stay, postoperative complications, and hip-knee-ankle (HKA) alignment. All procedures were performed using the principles of functional alignment. At most recent follow-up, range of motion (ROM), Forgotten Joint Score (FJS), and Oxford Knee Score (OKS) were collected. Mean follow-up time was 21 months (6 to 36).Aims
Methods
The statements contained in this document are solely those of the authors and do not necessarily reflect the views or
Meniscal allograft transplantation (MAT) for patients with symptomatic meniscal loss has demonstrated good clinical results and survivorship. Factors that affect both functional outcome and survivorship have been reported in the literature. These are typically single-centre case series with relatively small numbers and conflicting results. Our aim was to describe an international, two-centre case series, and identify factors that affect both functional outcome and survival. We report factors that affect outcome on 526 patients undergoing MAT across two sites (one in the UK and one in Italy). Outcomes of interest were the Knee injury and Osteoarthritis Outcome Score four (KOOS4) at two years and failure rates. We performed multiple regression analysis to examine for factors affecting KOOS, and Cox proportional hazards models for survivorship.Aims
Methods
This study aimed to describe the use of revision knee arthroplasty in Australia and examine changes in lifetime risk over a decade. De-identified individual-level data on all revision knee arthroplasties performed in Australia from 2007 to 2017 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population data and life tables were obtained from the Australian Bureau of Statistics. The lifetime risk of revision surgery was calculated for each year using a standardized formula. Separate calculations were undertaken for males and females.Aims
Methods
Nearly 99,000 total knee arthroplasties (TKAs) are performed in UK annually. Despite plenty of research, the satisfaction rate of this surgery is around 80%. One of the important intraoperative factors affecting the outcome is alignment. The relationship between joint obliquity and functional outcomes is not well understood. Therefore, a study is required to investigate and compare the effects of two types of alignment (mechanical and kinematic) on functional outcomes and range of motion. The aim of the study is to compare navigated kinematically aligned TKAs (KA TKAs) with navigated mechanically aligned TKA (MA TKA) in terms of function and ROM. We aim to recruit a total of 96 patients in the trial. The patients will be recruited from clinics of various consultants working in the trust after screening them for eligibility criteria and obtaining their informed consent to participate in this study. Randomization will be done prior to surgery by a software. The primary outcome measure will be the Knee injury and Osteoarthritis Outcome Score The secondary outcome measures include Oxford Knee Score, ROM, EuroQol five-dimension questionnaire, EuroQol visual analogue scale, 12-Item Short-Form Health Survey (SF-12), and Forgotten Joint Score. The scores will be calculated preoperatively and then at six weeks, six months, and one year after surgery. The scores will undergo a statistical analysis.Aims
Methods
Knee arthroplasty surgery is a highly effective treatment for arthritis and disorders of the knee. There are a wide variety of implant brands and types of knee arthroplasty available to surgeons. As a result of a number of highly publicized failures, arthroplasty surgery is highly regulated in the UK and many other countries through national registries, introduced to monitor implant performance, surgeons, and hospitals. With time, the options available within many brand portfolios have grown, with alternative tibial or femoral components, tibial insert materials, or shapes and patella resurfacings. In this study we have investigated the effect of the expansion of implant brand portfolios and where there may be a lack of transparency around a brand name. We also aimed to establish the potential numbers of compatible implant construct combinations. Hypothetical implant brand portfolios were proposed, and the number of compatible implant construct combinations was calculated.Aims
Methods
This study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA). Data for this study were collected from the National Surgery Quality Improvement Program (NSQIP) database from the year 2018. Patients who received a primary, elective, unilateral TKA with a diagnosis of primary osteoarthritis were included. Demographic, preoperative, and intraoperative variables were analyzed. The ANN model was compared to a logistic regression model, which is a conventional machine-learning algorithm. Variables collected from 28,742 patients were analyzed based on their contribution to hospital length of stay.Aims
Methods
The Oxford mobile bearing unicompartmental knee replacement (UKR) is a validated, highly successful implant with an excellent ten-year survivorship. From November 2001 to September 2006 three hundred and eighty two patients who had a medial cemented Oxford Unicompartmental knee replacement (Biomet, Bridgend, UK) via a minimally invasive approach were prospectively entered into a database and followed up as per departmental
We compared the practice of four orthopaedic consultants as regards the use of MRI and arthroscopy to diagnose problems of the knee. In one year 324 arthroscopies and 66 MR scans were performed for this purpose. We found that MRI is a reliable and cheaper alternative to ‘diagnostic arthroscopy’. We consider that patients with definite clinical signs merit an early ‘therapeutic arthroscopy’, but that all other knees should be investigated by MRI. This
Many patients undergoing total knee arthroplasty (TKA) have severe osteoarthritis (OA) in both knees and may consider either simultaneous or staged bilateral TKA. The implications of simultaneous versus staged bilateral TKA for return to work are not well understood. We hypothesized that employed patients who underwent simultaneous bilateral TKA would have significantly fewer days missed from work compared with the sum of days missed from each operation for patients who underwent staged bilateral TKA. The prospective arthroplasty registry at the Hospital for Special Surgery was used. Baseline characteristics and patient-reported outcome scores were evaluated. We used a linear regression model, adjusting for potential confounding variables including age, sex, preoperative BMI, and type of work (sedentary, moderate, high activity, or strenuous), to analyze time lost from work after simultaneous compared with staged bilateral TKA.Aims
Methods
Liposomal bupivacaine (LB) as part of a periarticular injection protocol continues to be a highly debated topic in total knee arthroplasty (TKA). We evaluated the effect of discontinuing the use of LB in a periarticular protocol on immediate postoperative pain scores, opioid consumption, and objective functional outcomes. On 1 July 2019, we discontinued the use of intraoperative LB as part of a periarticular injection protocol. A consecutive group of patients who received LB as part of the protocol (Protocol 1) and a subsequent group who did not (Protocol 2) were compared. All patients received the same opioid-sparing protocol. Verbal rating scale (VRS) pain scores were collected from our electronic data warehouse and averaged per patient per 12-hour interval. Events relating to the opiate administration were derived as morphine milligram equivalences (MMEs) per patient per 24-hour interval. The Activity Measure for Post-Acute Care (AM-PAC) tool was used to assess the immediate postoperative function.Aims
Methods
Alternative alignment concepts, including kinematic and restricted kinematic, have been introduced to help improve clinical outcomes following total knee arthroplasty (TKA). The purpose of this study was to evaluate the clinical results, along with patient satisfaction, following TKA using the concept of restricted kinematic alignment. A total of 121 consecutive TKAs performed between 11 February 2018 to 11 June 2019 with preoperative varus deformity were reviewed at minimum one-year follow-up. Three knees were excluded due to severe preoperative varus deformity greater than 15°, and a further three due to requiring revision surgery, leaving 109 patients and 115 knees to undergo primary TKA using the concept of restricted kinematic alignment with advanced technology. Patients were stratified into three groups based on the preoperative limb varus deformity: Group A with 1° to 5° varus (43 knees); Group B between 6° and 10° varus (56 knees); and Group C with varus greater than 10° (16 knees). This study group was compared with a matched cohort of 115 TKAs and 115 patients using a neutral mechanical alignment target with manual instruments performed from 24 October 2016 to 14 January 2019.Aims
Methods
The primary objective of this study was to compare migration of the cemented ATTUNE fixed bearing cruciate retaining tibial component with the cemented Press-Fit Condylar (PFC)-sigma fixed bearing cruciate retaining tibial component. The secondary objectives included comparing clinical and radiological outcomes and Patient Reported Outcome Measures (PROMs). A single blinded randomized, non-inferiority study was conducted including 74 patients. Radiostereometry examinations were made after weight bearing, but before hospital discharge, and at three, six, 12, and 24 months postoperatively. PROMS were collected preoperatively and at three, six, 12, and 24 months postoperatively. Radiographs for measuring radiolucencies were collected at two weeks and two years postoperatively.Aims
Methods
The purpose of this study was to determine the impact of the removal of total knee arthroplasty (TKA) from the Medicare Inpatient Only (IPO) list on our Bundled Payments for Care Improvement (BPCI) Initiative in 2018. We examined our institutional database to identify all Medicare patients who underwent primary TKA from 2017 to 2018. Hospital inpatient or outpatient status was cross-referenced with Centers for Medicare & Medicaid Services (CMS) claims data. Demographics, comorbidities, and outcomes were compared between patients classified as ‘outpatient’ and ‘inpatient’ TKA. Episode-of-care BPCI costs were then compared from 2017 to 2018.Aims
Methods