The efficacy and success of total knee arthroplasty (TKA) in treating patients with end-stage osteoarthritis are well established. However, revision rates range from 3 to 10% at 10-year follow-up. Reasons for failure include more obvious diagnoses, such as periprosthetic fracture and periprosthetic joint infection. With some exceptions, these complications can be diagnosed and treated expediently. However, other reasons for failure, such as instability and aseptic loosening, can prove more difficult to diagnose with a standard painful TKA workup algorithm.

Flexion instability has emerged as one of the most common causes of TKA failure in recent years. However, the diagnosis can be challenging as it remains difficult to predict patients who can tolerate laxity vs those who cannot. Without obvious radiographic changes over time, subtle aseptic loosening and, in particular, cemented implants, debonding, and failure of cementless ingrowth can also be difficult to accurately diagnose radiographically, and supplemental bone scans are known to have high false-positive and false-negative rates. Revision TKA without a clear diagnosis is not recommended due to poor results.

Read more

Throughout decades of history in total knee arthroplasty (TKA), the role of the posterior cruciate ligament (PCL) has been controversial. Some reports have shown inconsistent results with cruciate-retaining (CR) TKA. Yet other studies have found CR TKA to be advantageous over posterior-stabilized (PS) designs with respect to maintaining proprioception and knee kinematics. In the final analysis, however, a combined review of the literature has failed to show the superiority of either CR or PS TKA.

A third method that may be used to enhance posterior stability is to increase the sagittal plane conformity of the tibial polyethylene. This additional conformity may be achieved by an anterior buildup of the tibial insert. The so-called anterior-stabilized (AS) insert helps stabilize the femur during flexion and stair-climbing, potentially eliminating the need for a more traditional cam and post design.

Read more

Refinements in surgical technique, pain management, blood conservation, and rehabilitation have resulted in quicker recovery, providing a foundation for early discharge after 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 surgeons advocating an overnight stay to observe patients for life-threatening complications and those that will trigger a readmission. But is that overnight stay actually providing clinical value? Prior efforts to decrease expenditure by eliminating unnecessary health care modalities have proven to be effective in a variety of settings. Whether TJA patients discharged on postoperative day 1 (POD 1) receive beneficial medical interventions the night of surgery, necessitating their stay in the hospital, remains unknown.

Read more

Patient satisfaction following total knee arthroplasty (TKA) has been stagnant at around 80% without a clear understanding of the lingering 20% dissatisfaction. Satisfaction is a prominent topic in the literature, yet it remains a convoluted topic to understand. Factors reported to influence satisfaction in systematic reviews are meeting patient expectations, reduction in preoperative pain, and depression and anxiety. Other factors include medial flexion gap laxity, food received during a hospital stay, and even the use of therapy dogs.

Nonetheless, government payers have increased interest in basing surgeon reimbursement on patient satisfaction without a full understanding of the contributory factors. Therefore, it is imperative to identify the factors that influence patient satisfaction.

Read more

Total hip arthroplasty (THA) has conferred functional independence and improved quality of life for millions of patients in the United States and worldwide. Sadly, the operation of the century also has resulted in infection for as many as 1 (international registry data) to 2 (United States Medicare data) of every 100 patients. Absent reliable prevention measures for PJI, safe and effective treatment protocols to manage this complication have become an essential defense. Surgical treatments include irrigation and debridement (I&D) with implant retention; 1-stage exchange arthroplasty with implant removal and reimplantation in the same operative episode; and 2-stage exchange arthroplasty involving implant removal and placement of a temporary antibiotic-loaded spacer in the first surgery with a second surgery for reimplantation.

Two-stage treatment has been the gold standard in the United States, whereas 1-stage treatment is more common in Europe. The popularity of 1-stage exchange arthroplasty has been growing in the United States, with reports of comparable or better outcomes, reduced morbidity and mortality, enhanced quality of life, and cost savings. It is a concern, however, that conclusions implying the equivalence and in several cases the superiority of 1-stage treatment for PJI based on low-quality studies confounded by substantial heterogeneity in infection characteristics, patient comorbidities, bacterial profiles, details of treatment, definitions of PJI, and definitions of success are so rapidly influencing treatment decisions.

Read more

The COVID pandemic of 2020 has emerged as a global threat to patients, health care providers, and the global economy. Owing to this particular novel and highly infectious strain of coronavirus, the rapid community spread and clinical severity of the subsequent respiratory syndrome created a substantial strain on hospitals and health care systems around the world. The rapid surge of patients presenting over a small period for emergent clinical care, admission to the hospital, and intensive care units, with many requiring mechanically assisted ventilators for respiratory support, demonstrated the potential to overwhelm health care workers, hospitals, and health care systems.

Indiana University (IU) Health is the largest health system in the state of Indiana, with 2708 total beds and over 118,000 hospital admissions annually, and is partnered with the nation’s largest medical school, Indiana University School of Medicine. Through close cooperation with our state government and examination of available epidemiological models, IU Health determined that a surge of patients affected by the novel coronavirus would encounter our health system in late March and within an anticipated peak in mid to late April. Our program made the decision to stop all elective, nonurgent hip and knee arthroplasty surgery on March 17, 2020, and based on evolving data that became clear, the ambulatory aspect of patient care also ceased immediately.

Read more

Antibiotic-impregnated intramedullary dowels have historically been advocated and frequently used to facilitate and augment infection eradication via focused delivery of antibiotics into the intramedullary canals of the femur and tibia in periprosthetic knee infections during a 2-stage resection utilizing an antibiotic cement spacer. However, there is little literature on the use and efficacy of antibiotic-eluting intramedullary dowels in periprosthetic joint infection (PJI). There is also no published consensus recommendation on its use, as the topic was not reviewed in the recent International Consensus Meeting on PJI.

Hanssen and Spangehl recommend insertions of intramedullary dowel spacers irrespective of whether the implant has a stem, based on the assumption that around one-third of infected TKAs without stems have extension of the infectious process into the medullary canals of the femur or tibia. Furthermore, they argue that antibiotic dowels, as opposed to antibiotic beads, are easier to remove at reimplantation. Their recommendation was based on the study by McPherson et al., where they found that during resection, the most common site to yield positive operative cultures was from the medullary canal.

Read more

Two-stage treatment of periprosthetic knee infection employs either articulating or static high-dose antibiotic-eluding tibiofemoral cement spacers between resection and reimplantation, with or without antibiotic-eluding intramedullary (IM) dowels. Systematic reviews comparing articulating and static spacers do not address IM dowels but do provide general consensus that the 2 spacer types equivalently eradicate infection, although articulating designs result in improved range of motion and function following reimplantation.

After review and consideration of the available evidence, the 2018 International Consensus Meeting on Periprosthetic Joint Infection recommended the use of articulating spacers unless static spacers are indicated by severe bone loss, ligament insufficiency, or soft tissue compromise; however, the International Consensus group did not comment on the use of IM dowels to enhance treatment and facilitate the eradication of infection.

Read more

Although cemented total knee arthroplasty (TKA) is a widely successful procedure to treat many forms of arthritis, aseptic loosening remains one of the primary causes for early and late revisions. Studies and the 2017 national registries report that up to 28.7% of all revisions are due to aseptic loosening.

An evaluation of TKA failures estimated that 40% of early revisions could be avoided, in part, with optimal cement fixation. Increasing the amount of cement in the tibial and femoral bone (cement penetration) has been shown to provide a stronger bone-cement interface, which leads to increased stability and long-term survivorship of the implants.

Read more

Clinical and surgical care principles underlying modern, evidence-based care and coordination for early discharge total joint arthroplasty (TJA), also known as fast track, rapid recovery, or enhanced recovery from surgery, have led to an increased prevalence of short-stay and same-day discharge for appropriate patients. Acute postoperative urinary retention (POUR) is a significant barrier to same-day and early discharge TJA as it can result in pathologic bladder distention and injury, urinary tract infection (with possible hematogenous periprosthetic infection), and catheterization-related complications.

The incidence of acute POUR following TJA has been documented to range from 0% to 75%, varying based on the perioperative practices of TJA programs; characteristics of study populations; and definitions, measurement, and treatment methods for acute urinary retention. The incidence of POUR in fast-track TJA has been reported in recent years and is surprisingly high. Bjerregaard et al reported a 40% incidence in a prospective study of 1062 elective primary total hip arthroplasties(THAs) and total knee arthroplasties (TKAs) performed in highly established fast-track programs. Scholten et al reported a 31.3% incidence in 307 TJAs performed in another established fast-track center.

Read more

Over the last approximately 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 arthroplasty (THA) and total knee arthroplasty (TKA). Recently, this evolution was inadvertently accelerated as a result of confusion stemming from the removal of TKA from the inpatient-only list for Medicare patients by the Centers for Medicare and Medicaid Services Outpatient Prospective Payment System 2018 rule.

Combining the two-midnight rule and the removal of TKA from the inpatient-only list without defining justifying criteria for length of stay has inadvertently caused hospitals and payers to treat all Medicare TKA patients as outpatients, despite the intent of the Centers for Medicare and Medicaid Services that most Medicare TKA procedures would remain inpatient procedures.

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. Rapid recovery protocols have helped with a natural evolution of this procedure from the inpatient to the outpatient setting.

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

Historically, long-term success in total hip arthroplasty (THA) has been limited by implant loosening and late failure caused by osteolysis at the bone-implant interface due to third-body wear particles of conventional polyethylene. The historical critical threshold for osteolysis in conventional polyethylene is approximately 0.1 mm/y. Over the past 2 decades, advancements in polyethylene cross-linking and sterilization methods have made it possible to irradiate and remelt highly cross-linked polyethylene (HXLPE), which has shown improved tribological properties in biomechanical testing compared to conventional polyethylene, along with encouraging early and mid-term clinical results.

Recently, a sequential annealing process for HXLPE has been introduced with promising tribological and early clinical results compared to irradiated and remelted HXLPE. Few studies to date have reported the effects of femoral head material, femoral head size, and implant position on wear, creep, and head penetration rates for this sequentially annealed HXLPE. We set out to investigate the true mid-term wear rates of this specific material.

Read more

Pneumatic tourniquets are commonly used in total knee arthroplasty (TKA) to reduce intraoperative blood loss, enhance operative visualization, provide a cleaner field for cement penetration and fixation, and increase operative efficiency. However, the use of tourniquets during TKA has been a subject of debate in the scientific literature due to the risks and benefits associated with their use.

While pooled analyses consistently show less intraoperative blood loss with a tourniquet, they also point to a greater likelihood of thrombotic events, wound problems, and minor complications. Furthermore, several studies have demonstrated that tourniquets result in greater pain in the immediate postoperative period after TKA, with some studies additionally noting an increase in analgesic consumption.

Read more

There are multiple causes of recurrent dislocation after total hip arthroplasty (THA), including component malposition, extraprosthetic impingement, polyethylene wear, abductor muscle incompetence, altered neurologic or proprioception about the hip from neurologic disease or spinal disease, and, less commonly, adverse local tissue reaction from metal hypersensitivity or infection. Successful treatment of recurrent instability after THA requires an adequate assessment of the potential causal factors, an identification of the etiology, and a treatment approach targeting the specific etiology of the instability.

A detailed workup of the THA patient with recurrent instability is mandatory. As with all medical and surgical evaluations, a detailed history and physical examination are essential and must include the nature and direction of the instability. If the dislocation is an isolated event in the early postoperative period, within 3 months of surgery, with implants that are well-positioned, the patient can expect a reasonable chance of closed reduction, rendering the hip stable without further surgical intervention. Studies show a success rate of 67-81% for closed reduction of an early dislocation after a THA. Conversely, if more than once dislocation has occurred remote from the original surgery, the chance of closed reduction rendering the hip stable without further surgery is less likely.

Read more

Infection following total knee arthroplasty (TKA) remains one of the most dreaded and difficult complications to treat. The overall incidence of infection in the literature ranges between 0.5% and 2% for primary TKAs and 2% and 4% for revision TKAs. While successful eradication of periprosthetic joint infection (PJI) has been reported in the range of 85%-95%, the mortality associated with PJI is high.

Disruption of the extensor mechanism is an infrequent but catastrophic complication following TKA. Repair or reconstruction of the extensor mechanism disruption (EMD) is technically challenging. A recent longitudinal study of patients treated with extensor mechanism reconstruction (EMR) using allograft demonstrated 69% of knees retained the allograft at a mean follow-up of 68 months. However, the reoperation rate was high at 58%, with the most common reason for reoperation being the development of PJI at 26%.

Read more

Facing pressure to reduce length of stay and costs after total knee arthroplasty (TKA), many centers have begun to offer the procedure to select patients as an outpatient. While outpatient total joint arthroplasty has become more popular among patients and health care providers, concerns exist about an increase in complications from discharging patients home from the hospital too soon.

Private insurers have begun reimbursing hospitals and ambulatory surgical centers for outpatient TKA, but it remains on the Centers for Medicare and Medicaid Services (CMS) Inpatient Only (IPO) List. The IPO List was created in 2000 to identify surgical procedures that should be performed exclusively in an inpatient hospital setting. CMS has solicited public comments for the 2017 Proposed Rule to consider removing TKA from the list to offer patients and surgeons the option to perform TKA as an outpatient.

Read more

Total hip arthroplasty (THA) is one of the most successful surgical procedures in orthopedics, allowing patients with intractable pain and functional disability to return to higher levels of activity and experience an improved quality of life. In an era of decreasing reimbursement and bundled payments, surgeons and hospital systems are increasingly motivated to search for techniques to further reduce recovery time, postoperative pain, and hospital stay, while maintaining the excellent outcomes and safety profile of traditional methods.

The direct anterior approach (DAA) to THA has garnered significant attention in part due to claims that the approach is associated with less muscle damage and pain as well as accelerated recovery after hip arthroplasty. Although there has been a surge in popularity and widespread adoption and promotion of DAA THA by surgeons, hospitals, and industry, there are few studies that establish long-term clinically significant benefits, safety, and efficacy. Despite claims of superiority and significant marketing, several studies have been published raising concerns regarding nerve damage, muscle damage, blood loss, wound problems, femoral failure, and a technical learning curve.

Read more

The Centers for Medicare and Medicaid Services (CMS) established the Inpatient Only (IPO) list in 2000 to identify surgical procedures that should be performed exclusively in an inpatient hospital setting. Requirements to assign a procedure to the IPO list included the invasive nature of the surgery, the need for greater than 24 hours of postoperative care, and the underlying physical condition of the patient. Facilities are paid for procedures on the IPO list through the Inpatient Prospective Payment System, a separate payment structure that excludes reimbursement for an outpatient in both hospitals and ambulatory surgical facilities.

While total knee arthroplasty (TKA) has been on the IPO list since its inception in 2000, advances in blood conservation, pain management, and early mobilization have resulted in substantial reductions in hospital length of stay (LOS) after TKA and have now made outpatient TKA a reality for younger patients. Additionally, with a shift toward more TKAs being performed in ambulatory surgical centers, some surgeons have advocated for a policy change to give select, healthy Medicare beneficiaries the option to undergo TKA as an outpatient.

Read more

Total knee arthroplasty (TKA) continues to be a widely successful procedure by alleviating pain and restoring function for patients with degenerative disease of the knee. However, a significant number of patients continue to be dissatisfied with their TKA. Although patient dissatisfaction is multifactorial, the inability of total knee implants to restore native knee kinematics is likely a contributing factor.

Historically, the orthopedic world has debated between two main camps of knee design: posterior-stabilized and cruciate-retaining. Traditional posterior-stabilized total knee implant designs use a cam and post mechanism, which promotes roll back of the femur on the tibia during knee flexion. In contrast, traditional cruciate-retaining knee implants have a round-on-flat articulation that relies on an intact posterior cruciate ligament (PCL).

Read more