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Background: Staged bilateral total knee arthroplasty (TKA) is a common treatment option for patients with bilateral symptomatic knee osteoarthritis, yet some patients do not proceed with their second procedure. Our study aimed to identify the rate and reasons why patients did not proceed with their second procedure and compare their functional outcomes, satisfaction and complication rates with those of patients who had completed a staged bilateral TKA. Methods: We determined the proportion of patients who underwent TKA but did not proceed with planned surgery for the second knee within 2 years, and compared their satisfaction with surgery, improvement in the Oxford Knee Score (OKS) and complications between groups. Results: Our study included 268 patients: 220 patients who underwent staged bilateral TKA and 48 patients who cancelled their second procedure. The most common reason for not proceeding with the second procedure was a slow recovery after the first TKA (43.2%), followed by functional improvement in symptoms in the unoperated knee negating the need for surgery (27.3%), poor experience with the first surgery (22.7%), treatment of other comorbidities necessitating cancellation of their second procedure (4.6%) and employment reasons (2.3%). Patients who cancelled their second procedure were noted to have a worse postoperative OKS improvement (p < 0.001) and lower satisfaction rate (p < 0.001), than patients who underwent staged bilateral TKA. Conclusion: About one-fifth of patients scheduled for staged bilateral TKA declined to proceed with the second knee surgery within 2 years showing a substantially decreased functional outcome and satisfaction rate. However, more than one-quarter (27.3%) of patients noted improvements in their contralateral (unoperated) knee, such that a second surgery was no longer felt to be necessary. Contexte : L'arthroplastie totale du genou (ATG) bilatérale en séquence est une option courante pour l'arthrose du genou bilatérale symptomatique. Or, il arrive que la seconde intervention n'ait pas lieu. Notre étude a permis de déterminer le taux d'abstention de la seconde intervention et les motifs invoqués, et de comparer les résultats en termes de fonctionnement, de satisfaction et de complications selon qu'une seule ou les 2 interventions étaient effectuées. Méthodes : Nous avons vérifié la proportion de cas où la seconde ATG n'a pas été effectuée dans les 2 ans suivant la première, et nous avons comparé les 2 groupes aux plans du degré de satisfaction vis-à-vis de la chirurgie, de l'amélioration des scores au questionnaire Oxford d'évaluation du genou (ou OKS, pour Oxford Knee Score) et des complications. Résultats : Notre étude à inclus 268 patients : 220 qui ont subi l'ATG bilatérale en séquence et 48 qui ont décliné leur seconde intervention. Les motifs les plus souvent invoqués pour ne pas subir la seconde intervention étaient la lenteur du rétablissement suite à la première ATG (43,2 %), suivie de l'amélioration fonctionnelle des symptômes du genou non opéré rendant l'intervention superflue (27,3 %), l'expérience désagréable de la première intervention (22,7 %), un traitement pour des comorbidités qui a justifié l'annulation de la seconde intervention (4,6 %) et des raisons professionnelles (2,3 %). Les malades qui ont annulé leur seconde intervention ont eu une amélioration postopératoire moins bonne (p < 0,001) et un taux de satisfaction moins élevé (p < 0,001), que ceux qui ont subi l'ATG bilatérale en séquence. Conclusion : Environ le cinquième des cas planifiés d'ATG bilatérale en séquence ont refusé la deuxième intervention dans les 2 années suivant la première, cela s'est accompagné de résultats nettement moins favorables aux plans du fonctionnement et du taux de satisfaction. Toutefois, plus du quart (27,3 %) des cas ont noté des améliorations du genou non opéré, rendant la seconde chirurgie superflue., Total knee arthroplasty (TKA) is a common and successful treatment for patients with end-stage osteoarthritis. (1) Patients can present with bilateral knee osteoarthritis that requires surgical intervention necessitating discussion between [...]

Background: Femoral nerve block (NB) and periarticular injection (PI) are 2 common options for pain control after total knee arthroplasty (TKA). We performed a prospective triple-blinded randomized trial comparing continuous femoral NB to PI, with follow-up to 1 year. Methods: Patients younger than 70 years of age who were scheduled to undergo elective primary TKA under spinal anesthesia between 2009 and 2010 were randomly allocated to receive either continuous femoral NB or PI. Patients in the NB group received ropivacaine through an NB catheter and a sham saline PI. The PI group received a PI of ropivacaine, morphine, ketorolac and epinephrine, and a sham saline infusion via an NB catheter. Both groups had standardized oral analgesia preoperatively, spinal anesthesia and sedation, and postoperative analgesia. Surgeons, anesthesiologists, patients and assessors were blinded to group assignment. Pain was measured twice daily on postoperative days 1 and 2, at rest and with motion, with a numeric rating scale. Patient satisfaction, pain (Oxford Knee Score) and range of motion were assessed at 1 year. Results: There were 39 participants in the NB group and 35 participants in the PI group. There were no statistically significant differences between the groups at baseline. Statistically but nonclinically significant reductions in pain scores on postoperative day 2 and in narcotic need on the day of surgery were found in the PI group. Patient-reported satisfaction did not differ at any time point. At 1 year, knee flexion was significantly greater in the NB group than in the PI group (mean range of motion 120[degrees] v. 110[degrees], p = 0.03). Conclusion: There was no demonstrated improvement in pain control with the use of an NB versus PI when used with multimodal analgesia. Clinicians should opt for the modality that has the best efficiency for their surgical environment. ClinicalTrials.gov # NCT00869037 Contexte : Le bloc nerveux (BN) fémoral et l'infiltration périarticulaire (IP) sont 2 options d'usage courant pour maîtriser la douleur après l'arthroplastie totale du genou (ATG). Nous avons procédé à un essai prospectif randomisé à triple insu afin de comparer le BN fémoral et l'IP, avec un suivi allant jusqu'à 1 an. Méthodes : Les patients de moins de 70 ans qui devaient subir une ATG élective sous épidurale entre 2009 et 2010 ont été assignés aléatoirement à un BN fémoral continu ou à une IP. Les patients du groupe soumis au BN recevaient de la ropivacaïne par un cathéter de BN et une IF simulée (solution saline). Le groupe soumis à l'IP recevait de la ropivacaïne, de la morphine, du kétorolac et de l'épinéphrine et une perfusion simulée (solution saline) par un cathéter de BN. Les 2 groupes avaient reçu une analgésie orale standard avant l'intervention, une anesthésie rachidienne avec sédatifs et une analgésie postopératoire. Les chirurgiens, les anesthésiologistes, les patients et les évaluateurs ne connaissaient pas l'assignation des agents aux différents groupes. La douleur a été mesurée 2 fois par jour aux jours 1 et 2 postopératoires, au repos et à la mobilisation, au moyen d'une échelle numérique. La satisfaction des patients, la douleur (questionnaire d'Oxford pour le genou) et l'amplitude de mouvement ont toutes été évaluées après 1 an. Résultats : Le groupe soumis au BN comptait 39 participants et le groupe soumis à l'IP en comptait 35. Il n'y avait aucune différence statistiquement significative entre les groupes au départ. Des réductions statistiquement (et non cliniquement) significatives des scores de douleur au deuxième jour postopératoire et du recours aux narcotiques le jour de la chirurgie ont été notées dans le groupe soumis à l'IP. La satisfaction autodéclarée des patients n'a différé à aucun moment. Au bout de 1 an, la flexion du genou était significativement plus marquée dans le groupe soumis au BN que dans le groupe soumis à l'IP (amplitude de mouvement moyenne 120[degrees] c. 110[degrees], p = 0,03). Conclusion : On n'a démontré aucune amélioration de la maîtrise de la douleur avec l'utilisation du BN c. IP avec analgésie multimodale. Les médecins devraient opter pour la modalité qui offre le meilleur degré d'efficience en fonction de leur environnement chirurgical. ClinicalTrials.gov # NCT00869037, Total knee arthroplasty (TKA) is associated with considerable pain in the postoperative period. (1,2) This pain is most intense during the first few days after surgery but can last for [...]

Background: Body mass index (BMI) thresholds are used as eligibility criteria to reduce complication risk in total joint arthroplasty (TJA). This approach oversimplifies preoperative risk assessment and inadvertently restricts access to effective surgical treatment for osteoarthritis. A prior survey of orthopaedic surgeons in the United States identified complex underlying factors that influence BMI considerations. To understand whether similar factors exist and influence surgeons in a different health-care system setting, we investigated Canadian surgeons' views and use of BMI criterion thresholds for TJA access. Methods: A cross-sectional online qualitative survey was conducted with orthopaedic surgeons performing TJA in the Canadian health-care system. Responses were anonymous and questions were open-ended to allow for candid perspectives. Survey data were coded and a systematic process was followed to identify major themes. Findings were compared with U.S. surgeon perspectives. Results: Sixty-nine respondents had a mean age of 49.0 ± 11.4 years (range, 33 to 79 years), with a mean surgical experience duration of 15.7 ± 11.4 years (range, 2 to 50 years). Surgeons reported variable use of BMI thresholds in practice. Twelve interconnected factors that influence BMI considerations were identified: (1) variable evidence interpretation, (2) surgical challenge, (3) surgeon beliefs and biases, (4) hospital differences, (5) access to resources, (6) health system bias, (7) patient health status, (8) patient body fat distribution, (9) patient decisional burden (to lose weight or accept risk), (10) evidence gaps and uncertainties, (11) need for innovation, and (12) societal views. Nine themes matched with findings from U.S. surgeons. Conclusions: Parallel to the United States, complex, interconnected factors influence Canadian orthopaedic surgeons' variable use of BMI restrictions for TJA eligibility. Despite different health-care systems and reimbursement models, similar technical and personal factors were identified. With TJA practice guidelines advising against hard BMI criteria, attention regarding access to resources, surgical training, and innovations to address TJA complexity in patients with large bodies are critically needed. Future advancements in this sphere must balance barrier removal with risk reduction to ensure safe and equitable surgical care. Clinical Relevance: This study may influence surgeon behaviors with regard to hard BMI cutoffs for TJA and encourage critical thought about factors that influence decisions about surgical eligibility for patients with high BMI. [ABSTRACT FROM AUTHOR]

Background: Many practices require tissues from hip and knee arthroplasty procedures to be sent for pathologic examination. These examinations rarely provide information beyond the clinical or radiologic diagnosis and rarely alter clinical management. We aimed to determine the rate at which histologic diagnoses based on gross assessment alone or gross plus microscopic assessment correspond with reported clinical diagnoses in patients undergoing total joint arthroplasties and whether the histologic diagnoses alter patient management. Methods: We retrospectively reviewed arthroplasty cases performed at a high-volume teaching hospital in Manitoba, Canada. The clinical diagnosis was compared with the final pathology report based on gross examination, with or without histologic assessment. The results of the comparison were classified into 3 categories: concordant (same diagnosis), discrepant (different diagnoses without alterations in management) and discordant (different diagnoses resulting in management change). The overall provincial cost for pathologic examination was determined by multiplying the total examination cost by the estimated number of arthroplasty cases. Results: There were 773 patients in our study sample. The concordant rate was 98.3% (95% confidence interval [CI] 97.1%-99.1%), the discrepant rate was 1.7% (95% CI 0.9%-2.9%) and the discordant rate was 0.0% (95% CI 0%-0.5%) for 773 cases. The pathology diagnosis did not alter patient management in any case. A total of 91.5% of specimens did not require full histologic review and received gross descriptions only. The discrepancy rate was higher in cases that included microscopic examination than in those that received only gross descriptions (15.2% v. 0.4%, p < 0.001). The overall provincial cost for pathologic examination was estimated at Can$304 556. Conclusion: Submitting routine tissue from arthroplasty procedures to pathology does not affect patient management and therefore provides no value for the health care resources expended in doing so. Contexte : Beaucoup d'etablissements exigent que des tissus soient envoyes pour un examen anatomopathologique apres une arthroplastie de la hanche et du genou. Ces examens n'apportent generalement pas d'information nouvelle quant au diagnostic clinique ou radiologique et modifient rarement la prise en charge. Notre objectif etait de determiner le pourcentage de correspondance entre les diagnostics histologiques fondes sur l'inspection grossiere uniquement ou sur l'inspection grossiere et l'examen au microscope, et les diagnostics cliniques des patients qui subissent des arthroplasties totales. Nous cherchions egalement a savoir si les diagnostics histologiques modifient la prise en charge. Methodes : Nous avons procede a une analyse retrospective d'arthroplasties effectuees dans un grand h[delta]pital universitaire du Manitoba, au Canada. Le diagnostic clinique etait compare au rapport final de pathologie fonde sur une inspection grossiere, avec ou sans examen histologique. Les resultats de cette comparaison etaient classes en 3 categories : concordance (meme diagnostic), divergence (diagnostics differents, sans modification de la prise en charge) et discordance (diagnostics differents entrainant une modification de la prise en charge). Le cout global pour la province associe aux examens pathologiques a ete etabli en multipliant le cout total d'un examen par le nombre estime de cas d'arthroplastie. Resultats : Notre echantillon comprenait 773 patients. Le taux de concordance etait de 98,3 % (intervalle de confiance [IC] de 95 % 97,1 %-99,1 %), le taux de divergence etait de 1,7 % (IC de 95 % 0,9 %-2,9%) et le taux de discordance de 0,0 % (IC de 95 % 0 %-0,5 %). Dans tous les cas, le diagnostic pathologique n'a pas modifie la prise en charge. Au total, 91,5 % des specimens ne necessitaient pas d'examen histologique complet et n'ont fait l'objet que d'une inspection grossiere. Le pourcentage d'anomalie etait plus eleve pour les specimens analyses au microscope que pour ceux ayant uniquement subi une inspection grossiere (15,2 % c. 0,4 %, p < 0,001). Le cout total des examens pathologiques pour la province a ete estime a 304 556 $ CA. Conclusion : L'analyse pathologique systematique de tissus preleves lors d'arthroplasties n'entraine pas une modification de la prise en charge du patient; il n'y a donc pas de valeur associee aux ressources de sante utilisees pour ces examens., In many hospitals, pathologic specimens at the time of primary hip and knee arthroplasty are routinely sent for gross or microscopic examination regardless of the diagnosis. (1-3) The Joint Commission [...]

Background: Patient-specific cutting blocks in total knee arthroplasty have been promoted to improve mechanical alignment, reduce alignment outliers and improve patient outcomes. The aim of this study was to compare the efficacy of patient-specific instrumentation (PSI) and conventional instrumentation (CI) in achieving neutral alignment and accurate component positioning in total knee arthroplasty. Methods: We conducted a double-blinded randomized controlled trial in which patients were randomly assigned to treatment with either PSI or CI. Results: Fifty-four patients were included in the study. No relevant improvement in coronal alignment was found between the PSI and CI groups with post-hoc power of 0.91. Tibial slope was found to be more accurately reproduced to the preoperative target of 3[degrees] with PSI than with CI (3.8[degrees][+ or -] 3.1[degrees] v. 7.7[degrees][+ or -] 3.6[degrees], respectively, p < 0.001). There were no differences found in patient-reported outcome measures, surgical time or length of hospital stay. Conclusion: Given the added cost of the PSI technique, its use is difficult to justify given the small improvement in only a single alignment parameter. Clinical trial registration: Clinicaltrials.gov, no. NCT03416946. Contexte: L'utilisation de guides de coupe sur mesure dans l'arthroplastie totale du genou a ete recommandee pour ameliorer l'alignement mecanique, reduire les alignements extremes et ameliorer les resultats des patients. Cette etude cherchait a comparer la capacite des instruments sur mesure et des instruments classiques a engendrer un alignement neutre et un bon positionnement des composants dans le cadre d'une arthroplastie totale du genou. Methodes: Nous avons mene un essai clinique randomise a double insu. Les patients etaient repartis aleatoirement entre le groupe de traitement avec instruments sur mesure et le groupe de traitement avec instruments classiques. Resultats: Cinquante-quatre patients ont participe a l'etude. Aucune difference notable de l'alignement coronal entre les groupes n'a ete relevee, pour une puissance observee de 0,91. La pente tibiale correspondait plus exactement a la cible preoperatoire de 3[degrees] avec les instruments sur mesure qu'avec les instruments classiques (3,8[degrees] [+ or -] 3,1[degrees] contre 7,7[degrees] [+ or -] 3,6[degrees], respectivement; p < 0,001). Il n'y avait aucune difference dans les mesures declarees par les patients, la duree de l'intervention et la duree d'hospitalisation. Conclusion: Etant donne l'amelioration minime d'un seul parametre d'alignement et le cout superieur de la technique sur mesure, son utilisation est difficile a justifier. Enregistrement de l'essai: Clinicaltrials.gov, no NCT03416946., Total knee arthroplasty (TKA) is the current gold standard treatment for advanced knee arthritis. (1) The goal of TKA is to provide patients with an enhanced level of function and [...]

Background: A novel symmetric posterior condylar design and option of a femoral component with an outer zirconium oxide layer were introduced to a successful asymmetric condylar total knee arthroplasty system in 2005. Given the paucity of information on this modified design, we performed a study to determine its early to midterm survivorship and performance. Methods: Patients who received the Genesis II Symmetric Posterior Condyle or Legion Primary total knee (cobalt--chromium [CoCr] or oxidized zirconium--niobium [OxZr]) (Smith & Nephew) implanted at the study centre between March 2007 and December 2013 were enrolled into a prospective database. We retrospectively reviewed the database and performed survival analysis using Kaplan--Meier techniques. Results: There were 2178 patients (1359 women [62.4%]; mean age 64.6 yr; mean body mass index 35.0) with 2815 knee replacements available for analysis. Survival rates were 98.2% (95% confidence interval [CI] 97.6%-98.7%) for failure for any reason at 2 years and 96.8% (95% CI 96.0%-97.7%) at 5 years. Age (hazard ratio [HR] 0.97, 95% CI 0.94-0.997) and female sex (HR 0.45, 95% CI 0.27-0.75) were protective, whereas body mass index (HR 1.02, 95% CI 0.99-1.05) and OxZr implant (HR 1.11, 95% CI 0.57-2.18) did not influence survivorship. Oxford Knee Score values improved from a mean of 40.2 to 21.8 by 2 years (p < 0.001), with no difference between the CoCr and OxZr groups. Conclusion: The symmetric posterior condylar posterior-stabilized knee offers excellent midterm survivorship. Implant bearing surface did not have an influence on survivorship to 5 years, and, thus, use of OxZr implants may not be justified. Contexte: Un nouveau modele a condyles posterieurs symetriques et l'option d'un element femoral pourvu d'une couche d'oxyde de zirconium ont ete introduits avec succes dans un systeme de prothese totale du genou a condyles asymetriques en 2005. Compte tenu du manque de renseignements concernant ce modele modifie, nous avons procede a une etude pour en determiner la survie et le rendement a court et a moyen terme. Methodes: Les patients ayant recu la prothese a condyles posterieurs symetriques Genesis II ou une prothese totale primaire Legion (au cobalt--chrome [CoCr] ou au zirconium--niobium oxyde [OxZr]) (Smith & Nephew) au centre de recherche entre mars 2007 et decembre 2013 ont ete inscrits dans une base de donnees prospective. Nous avons procede a une revue retrospective de la base de donnees et effectue une analyse de survie a l'aide de techniques de Kaplan--Meier. Resultats: On a denombre 2178 patients (dont 1359 femmes [62,4%]; age moyen 64,6 ans; indice de masse corporelle moyen 35,0) totalisant 2815 arthroplasties du genou pour analyse. Les taux de survie ont ete de 98,2% (intervalle de confiance [IC] a 95% 97,6%-98,7%) pour le parametre defaillance de toutes causes a 2 ans et de 96,8% (IC a 95% 96,0%-97,7%) a 5 ans. L'age (risque relatif [RR] 0,97, IC a 95% 0,94-0,997) et le fait d'etre de sexe feminin (RR 0,45, IC a 95% 0,27-0,75) ont confere un effet protecteur, tandis que l'indice de masse corporelle (RR 1,02, IC a 95% 0,99-1,05) et l'implant OxZr (RR 1,11, IC a 95% 0,57-2,18) n'ont eu aucune influence sur la survie. Les scores Oxford d'evaluation du genou se sont ameliores, passant d'une moyenne de 40,2 a 21,8 en l'espace de 2 ans (p < 0,001), sans difference entre les groupes CoCr et OxZr. Conclusion: La prothese du genou a condyles posterieurs symetriques postero-stabilisee possede une excellente survie a moyen terme. La surface portant l'implant n'a pas eu d'influence sur la survie a 5 ans et, donc, l'utilisation d'implants OxZr ne sera peutetre pas justifiee., The Genesis II (Smith & Nephew) total knee implant system was released to the general market in 1996 and since its release has experienced good overall performance. Case series from [...]

Background: Timely access to orthopedic trauma surgery is essential for optimal outcomes. Regionalization of some types of surgery has shown positive effects on access, timeliness and outcomes. We investigated how [...]

Background: This study aimed to assess differences in the fixation and functional outcomes between pegged and keeled all-polyethylene glenoid components for standard total shoulder arthroplasty. Methods: Patients were randomized to [...]