Search

Value-based orthopaedic surgery and reimbursement changes for total knee arthroplasty (TKA) are potential factors shaping arthroplasty practice nationwide. This study aimed to evaluate (1) trends in discharge disposition (home vs nonhome discharge), (2) episode-of-care outcomes for home and nonhome discharge cohorts, and (3) predictors of nonhome discharge among patients undergoing TKA from 2011 to 2020. The National Surgical Quality Improvement Program database was reviewed for all primary TKAs from 2011 to 2020. A total of 462,858 patients were identified and grouped into home discharge (n = 378,771) and nonhome discharge (n = 84,087) cohorts. The primary outcome was the annual rate of home/nonhome discharges. Secondary outcomes included trends in health care utilization parameters, readmissions, and complications. Multivariable logistic regression analyses were performed to evaluate factors associated with nonhome discharge. Overall, 82% were discharged home, and 18% were discharged to a nonhome facility. Home discharge rates increased from 65.5% in 2011 to 94% in 2020. Nonhome discharge rates decreased from 34.5% in 2011 to 6% in 2020. Thirty-day readmissions decreased from 3.2 to 2.4% for the home discharge cohort but increased from 5.6 to 6.1% for the nonhome discharge cohort. Female sex, Asian or Black race, Hispanic ethnicity, American Society of Anesthesiology (ASA) class > II, Charlson comorbidity index scores > 0, smoking, dependent functional status, and age > 60 years were associated with higher odds of nonhome discharge. Over the last decade, there has been a major shift to home discharge after TKA. Future work is needed to further assess if perioperative interventions may have a positive effect in decreasing adverse outcomes in nonhome discharge patients.

In staged bilateral total knee arthroplasty (BTKA), the intersurgical time is yet to be determined. This study aimed to (1) test for differences in in-hospital metrics between the index and contralateral TKA and (2) determine the safest intersurgical time interval to minimize adverse outcomes after the contralateral surgery. The National Readmissions Database was queried for patients who received staged BTKA (2016–2017). A total of 20,279 patients were included. Demographics, comorbidities, baseline determinants, and intersurgical time between index and contralateral TKAs (≤ 3 month, 4–6 months, 7–9 months, and 10–12 months intervals) were captured. Outcomes included healthcare utilization (length of stay [LOS] and nonhome discharge), in-hospital costs, and in-hospital complications. Outcomes were compared between index versus contralateral surgeries and among contralateral surgeries of various intersurgical intervals. Contralateral surgeries had shorter LOS (2.2 ± 1.9 vs. 2.4 ± 2.0 days; p 0.05, each). Compared with the less than or equal to 3-month interval, the 4 to 6-month interval exhibited highest odds ratio (OR) of any infection (OR: 1.81; 95% confidence interval [CI]: [1.13–2.88]; p = 0.013), urinary tract infection (OR:1.81, 95%CI: [1.13–2.90]; p = 0.014), and any-cardiac complications (OR:1.17; 95%CI: [1.01–1.35]; p = 0.037). Patients in the 10–12-month cohort had lowest odds of posthemorrhagic anemia (OR: 0.84; 95% CI: [0.72–0.98]; p = 0.03). Overall, the second surgery of a staged BTKA has lower healthcare utilization despite similar complication rates. While patients in the 10 to 12-month intersurgical interval had the most favorable overall safety profile, no single interval exhibited consistently lower complications for all measured outcomes. Special care pathways should be optimized to care for patients undergoing staged BTKA.

Total knee arthroplasty (TKA) is the sole disease-modifying intervention for end-stage osteoarthritis. However, the temporal trends and stratification of age and patient demographics of pain and function levels at which surgeons perform TKA have not been characterized. The present investigation aimed to analyze the temporal trends of preoperative pain and functional patient-reported outcomes measures (PROMs) over the past 5 years when stratifying patient demographics. A prospective cohort of all patients who underwent primary elective TKA between January 2016 and December 2020 at a North American integrated tertiary health care system was retrospectively reviewed. The primary outcome was quarterly baseline (preoperative) pain and function PROM values before primary elective TKA. Evaluated PROMs included Knee Osteoarthritis Outcome Score (KOOS)-pain and KOOS-physical function shortform (PS) for the 5-year study period and were stratified by patient demographics (age, sex, race, and body mass index [BMI]). A total of 10,327 patients were analyzed. Preoperative pain levels remained unchanged over the study period for patients in the 45- to 64-year category (P-trend = 0.922). Conversely, there was a significant improvement in preoperative pain levels in the 65+ years group. Sex-stratified trends between males and females did not demonstrate a significant change in pre-TKA baseline pain over the study period (P-trend = 0.347 and P-trend = 0.0744). Both white and black patients demonstrated consistent KOOS-pain levels throughout the study period (P-trend = 0.0855 and P-trend = 0.626). Only white patients demonstrated improving preoperative KOOS-PS (P-trend = 0.0001), while black and “other” patients demonstrated consistent lower preoperative functional levels throughout the study period (P-trend = 0.456 and P-trend = 0.871). All BMI categories demonstrated relatively consistent preoperative KOOS-pain and KOOS-PS except for overweight and obese patients who demonstrated progressive improvement in preoperative KOOS-PS over the study period. Patients and surgeons are electing to perform primary TKA at higher levels of preoperative function. Stratification by race showed black patients did not experience a similar trend of improving function and exhibited a consistently lower functional level versus white patients. This disparity is likely to be multifactorial but may indicate underlying barriers to TKA access.

The purpose of this study was to compare (1) operative time, (2) in-hospital pain scores, (3) opioid medication use, (4) length of stay (LOS), (5) discharge disposition at 90-day postoperative, (6) range of motion (ROM), (7) number of physical therapy (PT) visits, (8) emergency department (ED) visits, (9) readmissions, (10) reoperations, (11) complications, and (12) 1-year patient-reported outcome measures (PROMs) in propensity matched patient cohorts who underwent robotic arm-assisted (RA) versus manual total knee arthroplasty (TKA). Using a prospectively collected institutional database, patients who underwent RA- and manual TKA were the nearest neighbor propensity score matched 3:1 (255 manual TKA:85 RA-TKA), accounting for various preoperative characteristics. Data were compared using analysis of variance (ANOVA), Kruskal–Wallis, Pearson's Chi-squared, and Fisher's exact tests, when appropriate. Postoperative pain scores, opioid use, ED visits, readmissions, and 1-year PROMs were similar between the cohorts. Manual TKA patients achieved higher maximum flexion ROM (120.3 ± 9.9 versus 117.8 ± 10.2, p = 0.043) with no statistical differences in other ROM parameters. Manual TKA had shorter operative time (105 vs.113 minutes, p

Total knee arthroplasty (TKA) is increasing in the elderly population; however, some patients, family members, and surgeons raise age-related concerns over expected improvement and risks. This study aimed to (1) evaluate the relationship between age and change in patient-reported outcome measures (PROMs); (2) model how many patients would be denied improvements in PROMs if hypothetical age cutoffs were implemented; and (3) assess length of stay (LOS), readmission, reoperation, and mortality per age group. A prospective cohort of 4,396 primary TKAs (August 2015–August 2018) was analyzed. One-year PROMs were evaluated via Knee injury and Osteoarthritis Outcome Score (KOOS)-pain, -physical function short form (-PS), and -quality of life (-QOL), as well as Veterans Rand-12 (VR-12) physical (-PCS) and mental component (-MCS) scores. Positive predictive values (PPVs) of the number of postoperative “failures” (i.e., unattained minimal clinically important difference in PROMs) relative to number of hypothetically denied “successes” from a theoretical age-group restriction was estimated. KOOS-PS and QOL median score improvements were equivalent among all age groups (p = 0.946 and p = 0.467, respectively). KOOS-pain improvement was equivalent for ≥80 and 60–69-year groups (44.4 [27.8–55.6]). Median VR-12 PCS improvements diminished as age increased (15.9, 14.8, and 13.4 for the 60–69, 70–79, and ≥80 groups, respectively; p = 0.002) while improvement in VR-12 MCS was similar among age groups (p = 0.440). PPV for failure was highest in the ≥80 group, yet remained 2, non-home discharge, and 90-day readmission were highest in the ≥80 group (8.11% [n = 24], p

Cementless fixation for total knee arthroplasty (TKA) has gained traction with the advent of newer fixation technologies. This study assessed (1) healthcare utilization (length of stay (LOS), nonhome discharge, 90-day readmission, and 1-year reoperation); (2) 1-year mortality; and (3) 1-year joint-specific and global health-related patient-reported outcome measures (PROMs) among patients who received cementless versus cemented TKA. Patients who underwent cementless and cemented TKA at a single institution (July 2015–August 2018) were prospectively enrolled. A total of 424 cementless and 5,274 cemented TKAs were included. The cementless cohort was propensity score-matched to a group cemented TKAs (1:3-cementless: n = 424; cemented: n = 1,272). Within the matched cohorts, 76.9% (n = 326) cementless and 75.9% (n = 966) cementless TKAs completed 1-year PROMs. Healthcare utilization measures, mortality and the median 1-year change in knee injury and osteoarthritis outcome score (KOOS)-pain, KOOS-physical function short form (PS), KOOS-knee related quality of life (KRQOL), Veteran Rand (VR)-12 mental composite (MCS), and physical composite (PCS) scores were compared. The minimal clinically important difference (MCID) for PROMs was calculated. Cementless TKA exhibited similar rates of median LOS (p = 0.109), nonhome discharge disposition (p = 0.056), all-cause 90-day readmission (p = 0.226), 1-year reoperation (p = 0.597), and 1-year mortality (p = 0.861) when compared with cemented TKA. There was no significant difference in the median 1-year improvement in KOOS-pain (p = 0.370), KOOS-PS (p = 0.417), KOOS-KRQOL (p = 0.101), VR-12-PCS (p = 0.269), and VR-12-MCS (p = 0.191) between the cementless and cemented TKA cohorts. Rates of attaining MCID were similar in both cohorts for assessed PROMs (p > 0.05, each) except KOOS-KRQOL (cementless: n = 313 (96.0%) vs. cemented: n = 895 [92.7%]; p = 0.036). Cementless TKA provides similar healthcare-utilization, mortality, and 1-year PROM improvement versus cemented TKA. Cementless fixation in TKA may provide value through higher MCID improvement in quality of life. Future episode-of-care cost-analyses and longer-term survivorship investigations are warranted.

Both advances in perioperative blood management, anesthesia, and surgical technique have improved transfusion rates following primary total knee arthroplasty (TKA), and have driven substantial change in preoperative blood ordering protocols. Therefore, blood management in TKA has seen substantial changes with the implementation of preoperative screening, patient optimization, and intra- and postoperative advances. Thus, the purpose of this study was to examine changes in blood management in primary TKA, a nationwide sample, to assess gaps and opportunities. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify TKA (n = 337,160) cases from 2011 to 2018. The following variables examined, such as preoperative hematocrit (HCT), anemia (HCT 2.0, bleeding disorders, preoperative, and postoperative transfusions. Analysis of variances were used to examine changes in continuous variables, and Chi-squared tests were used for categorical variables. There was a substantial decrease in postoperative transfusions from high of 18.3% in 2011 to a low of 1.0% in 2018, (p 2.0 of 1.0% in 2012 to 2015 and a low of 0.8% in 2016 to 2018 (p = 0.027). There was a high incidence of bleeding disorders of 2.9% in 2013 and a low of 1.8% in 2017 to 2018 (p

Newer generation cementless total knee arthroplasty (TKA) implants continue to develop with demonstrated clinical success in multiple recent reports. The purpose of this study was to investigate (1) survivorship, (2) complications, and (3) clinical outcomes of a newer generation cementless and highly porous titanium-coated base plate manufactured using three-dimensional (3D) printing technology. We reviewed a single-surgeon, longitudinally maintained database of patients who underwent primary TKA using cementless, highly porous titanium-coated base plate implants from July 1, 2013 to December 31, 2016. A total of 523 patients were identified. Of this cohort, 496 patients had a minimum of 2-year follow-up and were included in our final analysis. Among these patients, 72 had bilateral TKA yielding a total of 568 TKAs. There were 133 men and 363 women who had a mean body mass index of 33 kg/m2 (range, 20–61 kg/m2). The mean age was 66 years (range, 33–88 years). Average follow-up was 36 months (range, 24–48 months). Indications for TKA included osteoarthritis in 432 patients (87%), rheumatoid arthritis in 40 patients (8%), and knee osteonecrosis in 24 (5%) patients. Implant survivorship was defined as any revision leading to explantation of the base plate for any reason. Kaplan–Meier analysis was performed to determine all-cause implant survivorship at final follow-up for every patient. Complications were assessed using the Knee Society standardized list of TKA complications. Clinical outcomes were determined using the Knee Society pain and function scores. Range-of-motion values were also collected. There were a total of four failures, all were due to aseptic loosening with a survivorship rate of 99% at mean follow-up of 3 years (95% confidence interval = 0.984–0.999). In addition, there were a total of 12 surgical and 10 medical complications. Surgical complications did not affect the base plate or result in any additional implant revisions. A total of nine patients had thromboembolic disease complications; all received medical treatment and recovered adequately. Radiological evaluation did not show any signs of loosening or failures in other patients at final follow-up. Knee Society Scores for pain and function improved from 55 and 56 points preoperatively to 92 and 84 points at 2 years postoperatively. Our results are in concordance with the excellent clinical outcomes and survivorship demonstrated for the newer generation cementless TKA implants. In our experience, 3D printed titanium base plates demonstrated clinical success and excellent survivorship at minimum follow-up of 2 years.

The number of revision total knee arthroplasties (TKA) performed in the United States continues to increase. While advancements in implant design and surgical technique have led to improved outcomes compared with historical data, these cases remain technically demanding with high rates of aseptic failure and worse patient reported outcome scores compared with primary total knee arthroplasty. One particular problem commonly encountered in revision knee arthroplasty is bone loss, particularly in the epiphyseal region, which negatively impacts the structural integrity of the implants. Various modular metaphyseal sleeves and cones in conjunction with stemmed implants have been designed to enhance metaphyseal fixation, corroborated by multiple studies demonstrating excellent midterm results involving cones, and sleeves. Commercially available revision systems that incorporate metaphyseal cones are currently widely utilized in revision TKA. For tibial defects, both symmetric and asymmetric cone options are available. Excellent midterm results have been reported with use of this device in the setting of severe proximal tibial bone loss in revision TKA surgery. With the enhanced fixation provided by various sleeve and cone augments, implant removal in the setting of recurrent infection or implant failure can be extremely challenging. Consequently, in this work, we sought to describe an algorithmic approach for removing a tibial cone in conjunction with the overlying tibial baseplate. A review of the literature has also been conducted for complex surgical techniques regarding removal of well-fixed implants in revision total knee arthroplasty.

The ongoing debate on fixation in total knee arthroplasty (TKA) has become increasingly relevant with its increased use in a younger patient population and the advent of novel cementless prostheses. Recent literature suggests modern cementless implants are comparable to their cemented counterparts in terms of survivorship and functional outcomes. What has not been well-assessed is whether the two modalities differ with respect to infection rates which was the purpose of this study. Specifically, a propensity score matched study population was used to compare: (1) overall infection; (2) prosthetic joint infection (PJI); and (3) surgical site infection (SSI) rates between cementless and cemented TKAs. Using a large institutional database, 3,180 consecutive primary TKAs were identified. Cementless and cemented TKA patients were propensity score matched by age (p = 0.069), sex (p = 0.395), body mass index (BMI; p = 0.308), and Charlson's comorbidity index (CCI) score (p = 0.616) in a 1:1 ratio. Univariate analysis was performed to compare 2-year overall infection rates. Infections were further analyzed separately as PJIs (deep joint infections requiring surgery) and SSIs (skin/superficial wound infections). Multivariate logistic regression was performed to evaluate infection incidences after adjusting for procedure-related factors (i.e., operative time, hospital volume, and surgeon volume). There were no significant differences between the matched cohorts in terms of overall infection rates (3.8 vs. 2.3%, p = 0.722), as well as when PJI (p = 1.000) and SSI (p = 1.000) rates were analyzed separately. Multivariate analysis revealed no significant differences in overall postoperative infection rates (p = 0.285), PJI rates (p = 0.446), or SSI rates (p = 0.453) even after adjusting for procedure-related factors. There is increasing literature investigating various outcomes demonstrating the comparable efficacies of cementless versus cemented TKAs. To the best of the author's knowledge, this was the first matched case-control study to directly compare their post-operative infection rates. The findings from this study show that post-operative infection rates were similar between fixation modalities even after accounting for a range of patient- and procedure-related factors.

Revision total knee arthroplasty (TKA) can be challenging in the setting of bone loss. Previously, severe bone loss was managed with impaction grafting and structural allografts; however, these had limited success. Recently, metaphyseal cones have been developed as useful adjuncts with good early outcomes. Presently, there are no published guidelines on how to preoperatively predict the need for metaphyseal cone implantation radiographically. Therefore, the purpose of this study was to evaluate how well preoperative radiographs were able to predict the use of cones in a small series of patients undergoing revision TKA. In this study, three patients who were undergoing a revision TKA were evaluated radiographically. For each case, we used the Knee Society Roentgenographic Evaluation and Scoring System to assess for osteolysis and bone loss or defects. The intraoperative findings of bone loss that may have necessitated the use of cones were described and correlated with preoperative evaluation. The first patient had obvious osteolysis of both tibia and femur on anteroposterior (AP) and lateral radiographs. The preoperative radiographs predicted the need for a cone in both tibia and femur. The intraoperative findings correlated with preoperative radiographs. In the second case, there was obvious osteolysis of the tibia on AP and lateral films. The surgeon predicted the need of a tibial cone for tibial component placement based on these X-rays. The intraoperative findings confirmed this. In the third case, the patient had obvious osteolysis surrounding tibial component on both AP and lateral radiographs. The preoperative radiographs revealed the need for tibial cone only. Intraoperatively, the tibial findings correlated with the preoperative radiographs, but the femur revealed a large defect which required use of a metaphyseal cone. All three patients had marked radiolucencies and osteolysis surrounding the tibial component, and one of the three patients surrounding the femoral components. In this case series, the radiographs predicted the need for four out of five cones. The Knee Society Roentgenographic Evaluation and Scoring System may be a potential option for a radiographic evaluation method to predict the need for cones in revision TKA. It is hoped that this study will provide a starting point for future larger scale studies to assess the predictive need for cones in revision TKA.

The purpose of this study was to estimate the survivorship of the varus–valgus constrained (VVC) knee implants in primary, aseptic, and septic revision total knee arthroplasty (TKA); determine functional outcomes; main modes of failure; and variables associated with increased mechanical failures. In this study, 685 consecutive cases of primary (n = 247), aseptic (n = 315), and septic revision (n = 123) TKAs with VVC implants were performed between 1999 and 2008; 533 knees (78%) had a mean follow-up of 8.2 years (range, 2–15.1). Kaplan–Meier method was used to evaluate implant survival with mechanical failure as the end point. Clinical outcomes were measured with a modified Knee Society Score (mKSS) and modified Knee Function Score (mKFS) and modes of failure were determined. Cox proportional hazards models were performed to assess for factors associated with implant failure. Ten-year survival was 88.5% (95% confidence interval [CI]: 83.9–93.5%) for primary TKAs, 75.8% (95% CI: 70.4–81.7%) for aseptic, and 54.6% (95% CI: 43.7–68.2%) for septic revisions. Improvement in pre- to postoperative mKSS and mKFS were significant in all three groups (p

A recent development to better recreate joint kinematics has been a change from a multiradius (MR) design to a single radius (SR) design. We analyzed 559 primary total knee arthroplasty (TKA) procedures which used either a SR (n = 426 Triathlon; Stryker Orthopaedics, Mahwah, NJ) or MR of curvature knee system (n = 133 Duracon; Stryker Orthopaedics, Mahwah, NJ) (79.3% follow-up; 705 total TKA procedures identified). Patients were administered a modification of the Knee Society score (KSS) (3.9 years average follow-up). The SR design showed improvements over the MR design in pain (p = 0.021), stability (p = 0.002), flexion (p = 0.006), ability to completely straighten the knee (p = 0.025), stair climbing (p = 0.0001), walking (p = 0.0001), use of assistive devices (p = 0.0005), postoperative knee score (p = 0.0005), and postoperative function (p < 0.0001). Analysis of the change in KSS knee (p = 0.002) and function scores (p = 0.002) from preoperative visit to postoperative follow-up favored the SR design as well. These data support the use of SR implants and provide evidence of improved outcomes in terms of function, stability, and pain.