Aims

Surgeon and patient reluctance to participate are potential significant barriers to conducting placebo-controlled trials of orthopaedic surgery. Understanding the preferences of orthopaedic surgeons and patients regarding the design of randomized placebo-controlled trials (RCT-Ps) of knee procedures can help to identify what RCT-P features will lead to the greatest participation. This information could inform future trial designs and feasibility assessments.

Abstract. Introduction. A lipohaemarthrosis seen on Horizontal beam lateral X-ray in acute knee injury is often considered predictive of an intra-articular fracture requiring further urgent imaging. Methodology. We retrospectively searched a five-year X-ray database for the term “lipohaemarthrosis”. We excluded cases if the report concluded “no lipohaemarthrosis” or “lipohaemarthrosis” AND “fracture”. All remaining cases were reviewed by an Orthopaedic Consultant with a special interest in knee injuries (AD) blinded to the report. X-rays were excluded if a fracture was seen, established osteoarthritic change was present, a pre-existing arthroplasty present or no lipohaemarthrosis present. Remaining cases were then studied for any subsequent Radiological or Orthopaedic surgical procedures. Results. 136 cases were identified and reviewed by an Orthopaedic Consultant. 31 were excluded for no lipohaemarthrosis (n= 11), for degenerative change (n=9), for fracture (n=4), for existing arthroplasty (n=4) and for data errors (n=3). The remaining 105 patients had a mean age of 32, and range 5–90 years. 66 patients underwent further imaging in the form of MRI scan (n=47), CT Scan (n=9) repeat x-rays (n=9) and ultrasound (n=1). 27 fractures were identified. Surgery was performed in 12 cases (11%). Two (2%) urgently (One ACL reconstruction plus meniscus repair, one for ORIF of tibial plateau fracture). Ten (10%) had elective surgery (6 for ACL reconstruction, 2 for ACL reconstruction plus meniscus repair, 2 for loose body removal. Conclusion. The presence of a lipohaemarthrosis on x-ray following acute knee injury was a poor predictor of intra-articular fracture (26%) or need for urgent surgery (2%)

Introduction. The COVID-19 pandemic led to a swift adoption of telehealth in orthopedic surgery. The purpose of this study was to analyze patient and surgeon satisfaction with a rapid expansion of telehealth use during COVID-19 pandemic within the division of adult reconstructive surgery at a major urban academic hospital. Methods. 334 hip and knee arthroplasty patients who completed a telemedicine visit from March 30th, 2020 through April 30th, 2020 were sent a 14-question survey. Eight adult reconstructive surgeons who used telemedicine were sent a separate 14-question survey at the end of the study period. Factors influencing patient satisfaction were determined using univariate and multivariate ordinal logistic regression modeling. Results. 20.4% of patients (68/334) and 100% of surgeons (8/8) completed the surveys. Patients were on average “Satisfied” with their telemedicine visits (4.10/5.00 ± 0.98), 54.4% considered themselves high-risk for COVID-19 complications, and 27.9% reported that they preferred future visits to be conducted using telemedicine for reasons unrelated to COVID-19. Multivariate ordinal logistic regression modeling revealed that patients reported higher satisfaction if their surgeon effectively responded to their questions/concerns (OR 3.977; 95% CI 1.260 to 13.190, p=0.019) and if their visit had higher audiovisual quality (OR 2.46; 95% CI 1.052 to 6.219, p=0.042). Surgeons were “Satisfied” with their telemedicine experience (3.63/5.00 ± 0.92), felt that physical exams conducted via telemedicine were “Slightly Effective” (1.88/5.00 ± 0.99), and believed that 43.5% of visits required an in-person component. Most adult reconstructive surgeons would continue to use telemedicine in the future (87.5%). Conclusion. Telehealth emerged as a valuable tool during the COVID-19 pandemic. Arthroplasty patients and surgeons were generally satisfied with telehealth and see a role for telehealth after the pandemic. Future investigations should explore how to improve telehealth physical examinations and identify which types of visits and patient concerns are reliably addressed using telehealth

Introduction. Insufficient pain control following lower extremity surgery can increase length of stay, readmission rates, and impair postoperative outcome. It has been shown that CYP2D6 genotypes predict function of the enzyme responsible for conversion of hydrocodone to hydromorphone (active metabolite) and plasma concentration of hydromorphone best predicted analgesic response. Purpose of this study was to evaluate relationship of CYP2D6 genotypes, drug-drug interactions, and plasma drug concentrations in patients undergoing lower extremity surgery. Methods. A prospective cohort of 271 orthopedic patients undergoing lower extremity surgery including TKA, THA and trauma were queried. Patients treated with hydrocodone were enrolled and tested for plasma concentrations of hydrocodone and hydromorphone. CYP2D6 genotyping was performed. Medications co-administered with hydrocodone during perioperative and postoperative periods were queried. Results. Out of 271 patients enrolled, only 41 (15%) had detectable hydromorphone (i.e. >0.5 ng/mL). 86% were extensive (normal) metabolizers, 7% were intermediate metabolizers, 5% poor metabolizers and 2% were ultra rapid metabolizers. 179 subjects were not administered any inhibitors of CYP2D6 whereas 92 were on at least one inhibitor. 33 (18%) with no pharmacological inhibitors had detectable hydromorphone, whereas only 7 (7.6%) on inhibitors had hydromorphone detected above the lower limit of quantification (0.5ng/mL), p=0.033. Diphenhydramine, fluoxetine, hydralazine, duloxetine, bupropion and sertraline, were the most common CYP2D6 inhibitors co-administered with hydrocodone in this cohort. Conclusions. Patients' home medications and selection of various drugs in the postoperative setting could impact the pharmacokinetics and pharmacodynamics of hydrocodone leading to a diminished analgesic response. We conclude that health care providers should become familiar with the inhibitors of CYP2D6 to obtain the best response with the use of hydrocodone following lower extremity surgery. Additional work is required to determine the ideal opioid for an individual patient's genotype following lower extremity orthopedic surgery. For figures, tables, or references, please contact authors directly

Background. Optimal perioperative fluid management has not been established in patients undergoing orthopaedic surgical procedures. Our purpose was to investigate the effects of perioperative fluid management on patients experiencing TKA. Methods. One hundred thirty patients who met inclusion criteria undergoing primary unilateral TKA were prospectively randomized into traditional (TFG) vs. oral (OFG) perioperative fluid management groups. The TFG had a predetermined (4L) amount of intravenous fluids (IVF) administered in the perioperative period. The OFG began drinking a minimum of three, 20-ounces servings of clear fluids daily for three days prior to surgery. This cohort also drank 10-ounces of clear fluids 4 hours prior to surgery. Perioperative IVF were discontinued when the patient began oral intake or when the total amount of IVF reached 500mL. Outcome measures included: body-weight (BW) fluctuations, knee motion, leg girth, bioelectrical impendence, quadriceps activation, functional outcomes testing, KOOS JR, VR-12, laboratory values, vital signs, patient satisfaction, pain scores, and adverse events. Results. The TFG had increased BW the evening of surgery (7.0±4.3 vs. 3.0±3.9, p=0.000), post-operative day (POD) #1 (9.1±4.3 vs. 4.7±3.9, p=0.000), and POD #2 (6.2±5.0 vs. 4.4±4.0, p=0.032). Bioelectrical impedance showed less limb edema in the OFG (4.2±29.7 vs. 17.8±30.3, p=0.000) on POD#1. Urine specific gravity differences were seen preoperatively between groups (OFG, more hydrated, p=0.002). Systolic blood pressure decrease from baseline was greater in the OFG upon arrival to the floor (19.4±13.5 vs. 10.6±12.8, p=0.000) and 8 (23.4±13.3 vs. 17.0±12.9, p=0.006) and 16 (25.8±13.8 vs. 25.8±13.8, p=0.046) hours after floor arrival. The TFG had more UOP on POD#1 (3369mL±1343mL vs. 2435mL±1151mL). Conclusions. Oral fluid intake with IVF restriction in the perioperative period after TKA may offer short-term benefits with swelling and BW fluctuations. The authors continue to limit perioperative IVFs and encourage patient initiated fluid intake. For figures, tables, or references, please contact authors directly

Aims

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.

Total knee replacement and high tibial osteotomy are common orthopaedic operations with low complication rates. Such surgery is in close proximity to the popliteal artery (PA), the behaviour of which during flexion of the knee is poorly understood. We used Duplex ultrasonography to determine the distance of the PA from the posterior tibial surface at 0° and 90° of flexion in 100 knees. When the knee was flexed the PA was closer to the posterior tibial surface at 1 to 1.5 cm below the joint line in 24% and at 1.5 to 2 cm below the joint line in 15%. There was a high branching anterior tibal artery in 6% of knees. We provide an anatomical account to help to explain our findings by using cadaver dissections, arteriography and static MRI studies

Aims

It has been suggested that mobile-bearing total knee arthroplasty (TKA) might lead to better outcomes by accommodating some femorotibial rotational mismatch, thereby reducing contact stresses and polyethylene wear. The aim of this study was to determine whether there is a difference between fixed- and mobile-bearing versions of a contemporary TKA with respect to durability, range of movement (ROM) and function, ten years postoperatively.

We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs.

In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intra-operatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years).

There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029).

We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support.

Cite this article: Bone Joint J 2015;97-B:192–6.

Accurate, reproducible outcome measures are essential for the evaluation of any orthopaedic procedure, in both clinical practice and research.

Commonly used patient-reported outcome measures (PROMs) have drawbacks such as ‘floor’ and ‘ceiling’ effects, limitations of worldwide adaptability and an inability to distinguish pain from function. They are also unable to measure the true outcome of an intervention rather than a patient’s perception of that outcome.

Performance-based functional outcome tools may address these problems. It is important that both clinicians and researchers are aware of these measures when dealing with high-demand patients, using a new intervention or implant, or testing a new rehabilitation protocol.

This article provides an overview of some of the clinically-validated performance-based functional outcome tools used in the assessment of patients undergoing hip and knee surgery.

Cite this article: Bone Joint J 2014;96-B:1431–5.