Despite excellent long-term survivorship and outcomes after total knee arthroplasty (TKA) , patient satisfaction stubbornly lags behind that of total hip arthroplasty, with approximately 20% of unsatisfied patients. Unsatisfied patients experience pain, functional limitations, and describe an unnatural feel to the knee. To help close the gap on the subset of unsatisfied patients, there is increased interest in knee kinematics before and after TKA related to kinematic pivot patterns, which may help optimize patient-reported outcomes.

Traditionally, it was hypothesized that the optimal kinematic pivot pattern was predominantly medial through the range of motion. However, a modern understanding of kinematic pivot patterns in healthy knees and post-TKA knees may be nuanced with a more accurate description of a dual-pivot kinematic pivot pattern characterized by a lateral pivot in early flexion, which transitions to a medial pivot in mid to late flexion. Recently, this dual-pivot kinematic pivot pattern has shown superior patient-reported outcomes related to satisfaction and patients reporting their knee to always feel normal at 1-year after TKA compared with various other patterns.

Read more

Unicompartmental knee arthroplasty (UKA) is an attractive treatment option for unicompartmental osteoarthritis (OA) due to preservation of cruciate ligaments and bone stock, expedited recovery, reduced blood loss, and fewer complications compared to other surgical interventions. However, the decision of who is a good candidate for this procedure has been heavily influenced by historical guidelines.

In 1989, criteria were developed by Kozinn and Scott to guide surgeons with patient selection for UKA. Since its introduction, pre-existing patellofemoral arthropathy has been widely considered a contraindication by many surgeons. This means that for decades, if a patient had arthritis under their kneecap (the patellofemoral joint), they were typically disqualified from receiving a partial knee replacement and steered toward a total knee replacement instead.

More recently, some studies have argued that patellofemoral disease can be ignored in UKA; however, this supporting research is predominantly in mobile-bearing designs. We wanted to evaluate the effect of patellofemoral OA severity on the latest outcomes after fixed-bearing medial UKA.

Read more

A painful hip following total hip arthroplasty (THA) is concerning to patients and surgeons, particularly in the setting of satisfactory postoperative radiographs. Traditionally, most painful hips are caused by periprosthetic joint infection, component loosening, and instability. However, when these major mechanical issues are ruled out, both the patient and the physician can be left searching for answers.

Other less commonly reported causes of painful THAs persist and can be related to musculotendinous deficiencies, which include iliopsoas tendinitis and abductor mechanism disruption. These frequently underdiagnosed deficiencies are poorly understood in the literature and therefore challenging to resolve.

Read more

In the United States, same-day discharge (SDD) after primary hip and knee total joint arthroplasty (TJA) has evolved into an increasingly common practice. We know that when properly executed, SDD is highly effective. Nonetheless, failure to achieve planned SDD for primary TJA occurs in as many as 7% to 49% of patients in the United States.

As we push for more efficient, patient-friendly recovery pathways, it is critical to understand why these failures happen. To find out, we performed a retrospective analysis of prospectively collected data from 466 primary TJAs with planned SDD to home. Surgeries were performed at an academic tertiary care center comprising a hospital facility and a stand-alone ambulatory surgery center (ASC) on the same campus.

Read more

Enhancement of primary total joint arthroplasty (TJA) clinical and surgical protocols, cost containment, and recent shifts in Medicare policies have coalesced to promote the rapid growth of outpatient TJA. Identification of patients who can safely undergo outpatient TJA remains a top priority.

The Outpatient Arthroplasty Risk Assessment (OARA) score was previously developed to assign points to 52 comorbidities across 9 medical areas to generate a threshold score for safe patient selection.

Read more

Total joint arthroplasty (TJA) is among the most successful of orthopedic procedures performed. However, the exponentially increased demand for TJA has imposed an enormous economic burden on the healthcare system, accounting for more Medicare expenses than any other inpatient procedure. Not surprisingly, cost containment has become a focus of policy and research in TJA.

In 2016, a pilot study triggered by Anthem insurance found the average intraservice times for primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) to be less than the Centers for Medicare and Medicaid Services (CMS) benchmark of 100 minutes.

Read more

Total joint arthroplasty (TJA) is one of the most successful of orthopedic procedures. Evidence demonstrates early discharge primary TJA to be safe and cost saving, without increasing readmission rates.

However, despite the clinical success of primary TJA, complications requiring revision remain a costly societal burden. As the demand for TJA increases, so will the number of revisions.

Read more

Total joint arthroplasty (TJA) cost containment has been a key focus for the Centers for Medicare and Medicaid Services, spawning significant research and programmatic change, including a move toward early discharge and outpatient TJA.

Evidence has demonstrated early discharge TJA to be safe and cost-saving, without increasing readmission rates. However, discharge on the same day of surgery has been criticized as potentially hazardous, with some surgeons advocating an overnight stay to observe patients for life-threatening complications and those that will trigger a readmission.

Read more

Total joint arthroplasty (TJA) is among the most successful of orthopedic procedures performed. However, the exponentially increased demand for TJA has imposed an enormous economic burden on the healthcare system, accounting for more Medicare expense than any other inpatient procedure. Not surprisingly, cost containment has become a focus of policy and research in TJA.

Recently, the Centers for Medicare and Medicaid Services (CMS) asked the American Medical Association to re-evaluate the appropriateness of the relative value units (RVU) assigned to primary hip and knee replacements because average surgical times were dropping.

Nationally, many patients are undergoing early discharge primary TJA, with optimization occurring prior to surgery. But does an efficient, outpatient surgery mean the clinical team is doing less work?

Read more

The COVID pandemic of 2020 has emerged as a global threat to patients, health care providers, and the global economy. The rapid surge of patients presenting over a small period for emergent clinical care demonstrated the potential to overwhelm health care workers, hospitals, and health care systems.

In response, many institutions had to make difficult, unprecedented decisions. Our program made the decision to stop all elective, nonurgent hip and knee arthroplasty surgery on March 17, 2020.

But while routine surgeries paused, the need for orthopedic care did not vanish. We had to rethink how and where we delivered care to protect our patients and conserve resources.

We quickly learned that Ambulatory Surgery Centers (ASCs) were not just an alternative for elective surgery; they became a critical lifeline for the entire healthcare system.

Read more

Following 25 years of programmatic evolution and innovation, modern, evidence-based care and coordination for early discharge has become the desired standard of care in total joint arthroplasty (TJA).

With increasing utilization of the outpatient setting to perform hip and knee arthroplasty, acute postoperative urinary retention (POUR) has emerged as one of the most prevalent barriers to successful same-day discharge.

It can result in pathologic bladder distention and injury, urinary tract infection (with possible hematogenous periprosthetic infection), and catheterization-related complications.

Read more

Over the past decade and a half, there has been increasing interest in performing primary hip and knee replacement in the outpatient setting. This natural evolution has been aided immensely by rapid recovery protocols.

The interest in outpatient arthroplasty has also been fueled by financial considerations, including the ability to control costs within the episode of care, the potential for surgeon ownership in ambulatory surgery centers, and the ability for a surgeon to control his or her operating room and surgical care environment more easily in an ambulatory surgery center.

Read more

Over the last 15 years, rapid recovery protocols focused on multidisciplinary care coordination, standardized perioperative protocols, and careful discharge planning have created a natural evolution from the inpatient to outpatient setting for primary total hip and total knee arthroplasty.

However, data addressing the crucial question of “who is appropriate for same day discharge after total joint arthroplasty” has historically been limited to nonspecific surrogates such as the American Society of Anesthesiologists Physical Status (ASA-PS) classification system.

Read more

There has been increasing interest in outpatient primary total hip (THA) and knee (TKA) arthroplasties. This evolution has been made possible by rapid recovery protocols, multidisciplinary care coordination, and careful patient selection.

However, while the orthopedic community has embraced this shift, we realized we were missing a crucial piece of the puzzle: to the best of our knowledge, no studies have investigated patient perspectives on outpatient TJA.

Read more

Over the past decade, there has been a gradual increase in interest in performing primary hip and knee arthroplasties in the outpatient setting. However, outpatient arthroplasty has not been widely adopted, primarily because there is not yet a proven method for confidently identifying patients who can safely undergo outpatient hip and knee arthroplasties.

The most important aspect of performing an early discharge or outpatient arthroplasty is appropriately selecting patients to avoid putting them at undue risk.

Read more

For years, minimally invasive surgical (MIS) techniques in total hip arthroplasty (THA) have been heavily marketed, reportedly offering advantages like shorter hospital stays and more rapid rehabilitation.

As a result, patients often fixate on the specific type of incision, whether it’s a two-incision, mini-posterior, or mini-anterolateral approach, believing the surgical cut itself is the key to getting their life back quickly. But as someone who relies on evidence over marketing, I knew we needed to look closer.

Read more

Total knee arthroplasty (TKA) continues to demonstrate great outcomes; however, approximately one in five patients remains dissatisfied beyond 1-year follow-up. Advanced technologies, such as computer assistance, robotics, and smart sensors, have reduced implant placement outliers, allowing for improved surgical precision; however, intraoperative targets for implant placement and soft-tissue balance have yet to be defined.

These targets are commonly referred to as the “holy grail” of modern TKA, which may lead to the ultimate goal of re-creating native knee kinematics and, in turn, improvements in patient outcomes.

Read more

For decades, it has been accepted dogma in total knee arthroplasty (TKA) that resecting the posterior cruciate ligament (PCL) increases the flexion space by approximately 4mm. Because of this, surgeons were taught that sacrificing the PCL required elevating the joint line to avoid flexion instability.

Unfortunately, this doctrine is based on historical studies of limited size with variable technique. In many cases, these foundational studies were performed in cadaveric specimens where dynamic stabilizers were deficient, or in small cohorts heavily weighted to the female gender.

Read more

Satisfaction following primary total knee arthroplasty (TKA) remains stagnant at approximately 80%, leaving 1 in 5 patients unsatisfied with their procedure. For years, the orthopedic community has focused heavily on making the leg perfectly straight from side to side known as coronal alignment.

However, the majority of studies only evaluated the alignment in the coronal plane and neglected the sagittal plane, which is the front-to-back angle of the knee.

Read more

Patient dissatisfaction after total knee arthroplasty (TKA) lingers at approximately 20%. In an effort to solve this, technology related to robotic-assisted TKA is being rapidly promoted and adopted to reduce dissatisfaction rates because of its high reproducibility by minimizing outliers related to bone cuts.

But there is a catch. Although robotic-assisted TKA may help improve the precision of implant placement, there is currently no standardized approach for component alignment to allow precise and accurate TKA component placement.

Read more