Bone & Joint Surgery

Publons: The Next Step in Reviewer Recognition
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What’s New in Orthopaedic Trauma
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Use of Povidone-Iodine Irrigation Prior to Wound Closure in Primary Total Hip and Knee Arthroplasty: An Analysis of 11,738 Cases
imageBackground: Povidone-iodine (PI) irrigation is often used prior to wound closure in total joint arthroplasty, but there are limited reports evaluating its efficacy in decreasing joint infections. The goal of this study was to compare the rate of any reoperation for infection (both superficial and deep) in primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA) among patients who did and did not receive PI irrigation prior to wound closure. Methods: Using our institution’s total joint registry, we identified 5,534 primary THA and 6,204 primary TKA procedures performed from 2013 to 2017. Cases were grouped on the basis of whether or not the wound was irrigated with 1 L of 0.25% PI prior to closure. PI irrigation was used in 1,322 (24%) of the THA cases and in 2,410 (39%) of the TKA cases. The rates of reoperation for infection at 3 months and 1 year were compared between the 2 groups. The same comparisons were then performed using propensity scores to account for differences in baseline characteristics. Results: The rate of reoperation for infection as assessed at 3 months following THA was similar between those who received dilute PI irrigation (0.9%) and who did not (0.7%) (p = 0.7). At 1 year, the rate of reoperation for infection was similar between those who received dilute PI irrigation (0.7%) and those who did not (0.9%) (p = 0.6). After using the propensity score, there was no difference between the groups in the risk of septic reoperations. For TKA, the rate of reoperation as assessed at 3 months was similar between those who received dilute PI irrigation (0.8%) and those who did not (0.3%) (p = 0.06). At 1 year, there was a greater rate of reoperations for infection among those who received dilute PI irrigation (1.2%) compared with those who did not (0.6%) (p = 0.03). However, there was no difference in the risk of septic reoperations between the groups after using the propensity score. Conclusions: Despite enthusiasm for and progressive adoption of the use of dilute PI irrigation at our institution, there was not a significant reduction in the risk of reoperation for infection as assessed at 3 months and 1 year following primary THA and TKA. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Povidone-Iodine Wound Lavage to Prevent Infection After Revision Total Hip and Knee Arthroplasty: An Analysis of 2,884 Cases
imageBackground: Postoperative infection remains a major challenge in revision total hip arthroplasty (THA) and revision total knee arthroplasty (TKA). Wound irrigation with dilute povidone-iodine (PI) solution has emerged as a simple, inexpensive, and potentially successful means of reducing postoperative infections. The aim of this study was to assess its effectiveness in reducing infection following revision THA and TKA in, to our knowledge, the largest revision cohort to date. Methods: Using our institution’s total joint registry, we identified 1,402 revision THAs and 1,482 revision TKAs performed during the study period (2013, when the PI irrigation protocol was first implemented, to 2017). The PI lavage protocol was employed in 27% of the revision THA cases and 34% of the revision TKA cases; in the remaining cases, the protocol was not used. Demographics, comorbid conditions, underlying surgical diagnoses, and whether the revision was for a septic or an aseptic etiology were compared between the groups (use or no use of PI irrigation). Any reoperation due to infection, as assessed at 3 and 12 months following revision arthroplasty, was compared between the groups and propensity scores were calculated to account for differences in baseline characteristics between the groups. Results: After adjusting for baseline differences between the groups using the propensity-score weighted models, we found no significant difference in the rate of reoperation for infection at 3 months (p = 0.58 for revision THA, and p = 0.06 for revision TKA) and at 12 months (p = 0.78 for revision THA, and p = 0.06 for revision TKA). Nonetheless, the hazard ratios from the propensity-score model trended higher for patients who received PI lavage: 1.6 and 1.3 for revision THA at 3 and 12 months, respectively, and 2.9 at both 3 and 12 months for revision TKA. Conclusions: PI wound lavage demonstrated no benefit in reducing any reoperation for infection following revision THA and TKA. Moreover, the trend toward higher rates for reoperation for infection among patients who received PI irrigation merit further consideration. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Association of Race and Ethnicity with Total Hip Arthroplasty Outcomes in a Universally Insured Population
imageBackground: Prior studies have documented racial and ethnic disparities in total hip arthroplasty (THA) outcomes in the U.S. The purpose of this study was to assess whether racial/ethnic disparities in THA outcomes persist in a universally insured population of patients enrolled in an integrated health-care system. Methods: A U.S. health-care system total joint replacement registry was used to identify patients who underwent elective primary THA between 2001 and 2016. Data on patient demographics, surgical procedures, implant characteristics, and outcomes were obtained from the registry. The outcomes analyzed were lifetime revision (all-cause, aseptic, and septic) and 90-day postoperative events (infection, venous thromboembolism, emergency department [ED] visits, readmission, and mortality). Racial/ethnic differences in outcomes were analyzed with use of multiple regression with adjustment for socioeconomic status and other potential confounders. Results: Of 72,755 patients in the study, 79.1% were white, 8.2% were black, 8.5% were Hispanic, and 4.2% were Asian. Compared with white patients, lifetime all-cause revision was lower for black (adjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.66 to 0.94; p = 0.007), Hispanic (adjusted HR, 0.73; 95% CI, 0.61 to 0.87; p = 0.002), and Asian (adjusted HR, 0.49; 95% CI, 0.37 to 0.66; p < 0.001) patients. Ninety-day ED visits were more common among black (adjusted odds ratio [OR], 1.15; 95% CI, 1.05 to 1.25; p = 0.002) and Hispanic patients (adjusted OR, 1.18; 95% CI, 1.08 to 1.28; p < 0.001). For all other postoperative events, minority patients had similar or lower rates compared with white patients. Conclusions: In contrast to prior research, we found that minority patients enrolled in a managed health-care system had rates of lifetime reoperation and 90-day postoperative events that were generally similar to or lower than those of white patients, findings that may be related to the equal access and/or standardized protocols associated with treatment in the managed care system. However, black and Hispanic patients still had higher rates of 90-day ED visits. Further research is required to determine the reasons for this finding and to identify interventions that could reduce unnecessary ED visits. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
Regional or General Anesthesia in the Surgical Treatment of Distal Radial Fractures: A Randomized Clinical Trial
imageBackground: Most patients undergoing surgery for the treatment of a distal radial fracture are treated in a day-surgery setting and are given either general anesthesia (GA) or regional anesthesia (RA). The main purpose of this study was to investigate the impact of the anesthesia method on patients’ postoperative opioid consumption during the first 3 days following surgery. Methods: This was a single-center randomized clinical trial. A total of 88 patients aged 18 to 74 years who were undergoing day surgery for the treatment of a displaced distal radial fracture with volar-plate fixation were randomized to GA (n = 44) or RA with a supraclavicular brachial plexus blockade (n = 44). The primary outcome was total opioid equivalent consumption (OEC) during the first 3 postoperative days (72 hours). Secondary outcomes included OEC during days 1, 2, and 3, visual analog scale (VAS) for pain scores, maximum pain, postoperative nausea and vomiting, perioperative time consumption (surgical, preoperative, and postoperative anesthesia care time), functional outcomes, and Patient-Rated Wrist Evaluation (PRWE) and EuroQol-5 Dimensions-3 Levels (EQ-5D-3L) scores up to 6 months. Results: The total median OEC during the first 3 postoperative days was 85 mg (range, 0 to 218 mg) in the GA group and 60 mg (range, 3 to 150 mg) in the RA group (p = 0.1). The groups differed significantly in OEC and VAS for pain scores during the first 24 hours after surgery; the median OEC was higher in the GA group before discharge (p < 0.001), while it was higher in the RA group after discharge (p < 0.001). Patients in the GA group reported more pain immediately after surgery (median score, 6; width of interquartile range [IQR], 7) and at 2 hours postoperatively (median score, 2; width of IQR, 3) compared with patients in the RA group (median score, 0; width of IQR, 0 at both time points) (p < 0.001). Maximum pain occurred at a median of 1 hour (range, 1 hour to 22 hours) after the end of surgery in the GA group compared with a median of 11 hours (range, 1 hour to 24 hours) in the RA group (p < 0.001). The total median perioperative time consumption was 244 minutes (range, 114 to 389 minutes) in the GA group compared with 146 minutes (range, 74 to 390 minutes) in the RA group (p < 0.001). There were no significant differences in functional outcomes or PRWE or EQ-5D-3L scores at 6 months. Conclusions: The anesthesia method (GA vs. RA) significantly influenced the early patterns of postoperative pain and opioid consumption after surgical treatment of a distal radial fracture, but neither total OEC over the first 3 postoperative days nor longer-term outcomes differed between the groups. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Step Activity After Surgical Treatment of Ankle Arthritis
imageBackground: Ambulatory activity is reduced in patients with ankle arthritis. In this study, we measured step activity over time in 2 treatment groups and secondarily compared step activity with results of patient-reported outcome measures (PROMs). Methods: Patients who were treated with either ankle arthrodesis or ankle arthroplasty wore a step activity monitor preoperatively and at 6, 12, 24, and 36 months postoperatively. Changes from preoperative baseline in total steps per day and per-day metrics of low, medium, and high-activity step counts were measured in both treatment groups. Step activity was compared with each subject’s PROM scores as reported on the Musculoskeletal Function Assessment (MFA) and the Short Form-36 (SF-36) physical function and bodily pain subscales. Results: Of the 3 activity levels, combined group high-activity step counts showed the greatest increase (mean of 278 steps [95% confidence interval (CI), 150 to 407 steps], a 46% improvement from preoperatively). At 6 months, the mean high-activity step improvement for the arthroplasty group was 194 steps compared with a mean decline of 44 steps for the arthrodesis group (mean 238-step difference [95% CI, −60 to 536 steps]). By 36 months postoperatively, the greater improvement in high-activity steps for the arthroplasty versus the arthrodesis group was no longer present. There were no significant pairwise differences in improvement based on surgical treatment method at any individual follow-up time point. For a within-patient increase of 1,000 total steps, there was a mean change in the MFA, SF-36 physical function, and SF-36 bodily pain scores of −1.8 (95% CI, −2.4 to −1.2), 3.8 (95% CI, 2.8 to 4.8), and 2.8 (95% CI, 1.8 to 3.9), respectively (p < 0.0001 for all associations). There was no evidence that the association differed by study visit, or by study visit and surgical procedure interaction (p > 0.10). Conclusions: Surgical treatment of ankle arthritis significantly improves ambulatory activity, with greater change occurring at high activity levels. Improvement may occur more quickly following arthroplasty than arthrodesis, but at 3 years, we detected no significant difference between the 2 procedures. Step counts, while associated with PROMs, do not parallel them, and thus may be a useful supplementary measure, particularly in longitudinal studies. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Cemented Versus Cementless Total Knee Arthroplasty of the Same Modern Design: A Prospective, Randomized Trial
imageBackground: Highly porous surfaces promoting biologic fixation have renewed interest in cementless total knee arthroplasty (TKA), but the potential for failed biologic fixation remains. The purpose of this study was to compare the clinical outcomes of cemented and cementless versions of the same TKA design at an average of 2 years postoperatively. Methods: This was an institutional review board-approved, prospective, randomized controlled trial of patients from 18 to 75 years of age who were undergoing a primary TKA. Patients with inflammatory arthritis, a body mass index (BMI) of >40 kg/m2, infection, a neuromuscular disorder, or grossly osteoporotic bone or bone defects were excluded. Patients were randomized to receive a cemented or cementless cruciate-retaining TKA of the same design. The cementless implant has highly porous fixation surfaces. Oxford Knee, Knee Society, and Forgotten Joint Scores were collected. Patients were asked to rate the knee with the TKA as a percentage of normal. Power analysis indicated that 130 patients were necessary to demonstrate a 5-point difference in the Oxford Knee Score at 90% power. Results: One hundred and forty-seven patients were enrolled, and 141 (96%) of them were analyzed at an average of 2 years postoperatively. There was no difference in age, sex, BMI, American Society of Anesthesiologists (ASA) score, or duration of follow-up (p = 0.1 to 0.9). There was also no difference in the change in the hemoglobin level from the preoperative measurement to postoperative day 1 between the 2 cohorts (mean and standard deviation, −2.6 ± 1.4 g/dL compared with −2.5 ± 0.9 g/dL, p = 0.5), but the total operative time was decreased in the cementless cohort (82.1 ± 16.6 compared with 93.7 ± 16.7 minutes, p = 0.001). There were no differences in any clinical outcome measure at 4 to 6 weeks, 1 year, or an average of 2 years postoperatively (p = 0.1 to 0.9) between the cemented and cementless cohorts. There was no radiographic evidence of component subsidence or loosening in either cohort. Conclusions: This study demonstrated that a recently introduced cementless TKA had results, both perioperatively and at an average of 2 years postoperatively, that were equivalent to those of its cemented predecessor, without any aseptic failures of either implant. Thus, this study justifies continued surveillance of this device to elucidate both its survivorship and if it can provide any long-term benefits. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Virtual Mechanical Testing Based on Low-Dose Computed Tomography Scans for Tibial Fracture: A Pilot Study of Prediction of Time to Union and Comparison with Subjective Outcomes Scoring
imageBackground: Quantitative outcomes assessment remains a persistent challenge in orthopaedic trauma. Although patient-reported outcome measures (PROMs) and radiographic assessments such as Radiographic Union Scale for Tibial Fractures (RUST) scores are frequently used, very little evidence has been presented to support their validity for measuring structural bone formation or biomechanical integrity. Methods: In this pilot study, a sequential cohort of patients with a tibial shaft fracture were prospectively recruited for observation following standard reamed intramedullary nailing in a level-I trauma center. Follow-up at 6, 12, 18, and 24 weeks included radiographs and completion of PROMs (EuroQol 5-Dimension [EQ-5D] and pain scores). Low-dose computed tomography (CT) scans were also performed at 12 weeks. Scans were reconstructed in 3 dimensions (3D) and subjected to virtual mechanical testing via the finite element method to assess torsional rigidity in the fractured limb relative to that in the intact bone. Results: Patients reported progressive longitudinal improvement in mobility, self-care, activity, and health over time, but the PROMs were not correlated with structural bone healing. RUST scoring showed moderate intrarater agreement (intraclass coefficient [ICC] = 0.727), but the scores at 12 weeks were not correlated with the time to union (R2 = 0.104, p = 0.193) and were only moderately correlated with callus structural integrity (R2 = 0.347, p = 0.010). In contrast, patient-specific virtual torsional rigidity (VTR) was significantly correlated with the time to union (R2 = 0.383, p = 0.005) and clearly differentiated 1 case of delayed union (VTR = 10%, union at 36 weeks) from the cases in the normally healing cohort (VTR > 60%; median union time, 19 weeks) on the basis of CT data alone. Conclusions: PROMs provide insight into the natural history of the patient experience after tibial fracture but have limited utility as a measure of structural bone healing. RUST scoring, although reproducible, may not reliably predict time to union. In contrast, virtual mechanical testing with low-dose CT scans provides a quantitative and objective structural callus assessment that reliably predicts time to union and may enable early diagnosis of compromised healing. Level of Evidence: Therapeutic Level IV. Please see Instructions for Authors for a complete description of levels of evidence.
The Effect of Coronal Alignment on Tibial Component Migration Following Total Knee Arthroplasty: A Cohort Study with Long-Term Radiostereometric Analysis Results
imageBackground: Recent short-term studies of total knee arthroplasty (TKA) have claimed improved clinical outcomes and implant survival when aiming to restore constitutional joint kinematics, as compared with neutral mechanical axis alignment. However, implant durability may be compromised when aligned in varus or valgus. With use of data pooled from 3 long-term radiostereometric analysis (RSA) studies, the aim of the present study was to assess the effects of coronal alignment on tibial component migration. Methods: Coronal alignment parameters from full-leg radiographs were measured and the constitutional leg alignment was determined for each patient. We evaluated the effect of the postoperative hip-knee-ankle angle, relative to both the mechanical axis and the constitutional alignment, on tibial component migration. In-range knees were defined as within ±3° of either the neutral mechanical axis or constitutional alignment of the patient. Analysis was performed with a linear mixed-effects model, corrected for study, age, sex, preoperative alignment, diagnosis, and body mass index. Results: A total of 85 cemented TKAs were included, of which 3 were revised for aseptic loosening and another 4 were considered loose. The median follow-up was 11 years. No loose tibial components were observed in mechanically in-range knees, whereas all loose tibial components were out of range. Mechanically varus knees showed the highest mean migration (maximum total point motion) of 1.55 mm (95% confidence interval [CI], 1.16 to 2.01 mm) after 5 years, compared with 1.07 mm (95% CI, 0.63 to 1.64 mm) and 0.77 mm (95% CI, 0.53 to 1.06 mm) for valgus and in-range knees, respectively (p < 0.001). In contrast, looking at constitutional alignment, loose tibial components were found among both constitutionally in-range and out-of-range knees. Mixed-model analysis showed comparable migration among constitutionally in-range, more-in-varus, and more-in-valgus aligned knees. Conclusions: Mechanically out-of-range alignment, especially mechanical varus, led to higher tibial component migration. However, matching the constitutional alignment of the patient did not preclude high implant migration. RSA trials randomizing different alignment techniques are needed to confirm the results of the present study. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos


Bone & Joint Surgery


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