The Centers for Medicare & Medicaid Services (CMS) mandates patient-reported outcome measure (PROM) reporting for inpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) starting July 1, 2024, requiring preoperative (zero to 90 days) and postoperative (300 to 425 days) scores for ≥ 50% of claims. Substantial clinical benefit (SCB) is defined as a 22-point Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS-JR) improvement for THA and a 20-point Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS-JR) improvement for TKA, with a CMS-defined goal for hospitals to achieve SCB for ≥ 60% of patients. The purpose of this study was to assess the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) sites' readiness to meet these CMS PROM collection requirements and their success in achieving SCB thresholds.

We analyzed 8,826 THAs and 12,210 TKAs performed between January 1, 2022, and June 30, 2022, in MARCQI. Matched pre- and postoperative PROMs and SCB rates were assessed across 81 sites.

Only 22.1% of the patients who underwent THA and 22.7% of the patients who underwent TKA had matched PROMs, and 7.4% of sites met CMS thresholds for collection. However, 90% of sites with matched PROMs met the SCB threshold.

For a statewide registry in Michigan, few sites met CMS collection requirements, but most achieved SCB targets. These findings reflect the experience of a diverse group of MARCQI sites and may not be generalizable to other states or institutions.

Total knee arthroplasty (TKA) alters the lower extremity alignment, potentially affecting adjacent joints such as the ankle and subtalar joints. However, the relationship between changes in hindfoot alignment and ankle osteoarthritis (OA) after TKA remains incompletely understood. The purpose of this study was to clarify whether ankle and subtalar alignment normalizes after TKA and to identify factors associated with persistent malalignment.

We retrospectively analyzed 331 patients who underwent unilateral mechanical alignment (MA) TKA for knee osteoarthritis. A control group of 40 healthy subjects was used to define normal alignment ranges. Whole-leg anteroposterior weight-bearing radiographs were obtained preoperatively and 2 months postoperatively. Alignment parameters included the hip-knee-ankle angle (HKA), tibiotalar tilt angle (TTA), tibial plafond inclination angle (TPIA), talar inclination angle (TIA), and hindfoot alignment angle (HAA). Pre- and postoperative values were compared using the Wilcoxon signed-rank test, and changes in the proportion of patients within the normal range were determined. Wilcoxon rank-sum tests and chi-squared tests were used for group comparisons, and multivariate logistic regression identified independent predictors of persistent malalignment.

HKA improved after TKA (-12° to -2.0°), with corresponding improvements in TPIA (99° to 94°) and TIA (99° to 95°) (all p < 0.001), indicating a significant correction toward neutral alignment. The proportion of patients within normal range increased postoperatively from 16% to 85% for HKA, 26% to 67% for TPIA, 24% to 64% for TIA, and 65% to 73% for HAA. Multivariate analysis identified ankle OA (odds ratio [OR] = 6.62 for TTA), female sex (OR = 2.32 for TPIA; OR = 3.19 for TIA), and varus knee alignment (OR = 2.81 for TIA) as independent predictors of persistent malalignment.

MA-TKA facilitates partial normalization of coronal hindfoot alignment, particularly at the tibial plafond and talus. However, female sex, varus knee deformity, and pre-existing ankle OA independently limit full correction. These findings highlight the biomechanical interdependence between the knee and hindfoot and may guide surgical decision-making and patient-specific alignment strategies.

Primary robotic-assisted (RA) TKA is becoming increasingly common worldwide. However, there are currently no reports of RA TKA utilizing a bi-cruciate ligament-retaining (BCR) prosthetic design. The aim of this study was to perform intra-operative gap assessment with the goal of improving post-operative patient-reported outcome measures (PROMs) at a mean follow-up of 20.4 months in patients undergoing RA BCR TKA. The study included 33 knees with knee osteoarthritis who underwent BCR TKA using RA techniques. Intra-operative soft tissue balance was assessed by evaluating the medial joint gap (MJG), lateral joint gap (LJG). The femoro-tibial angle (FTA), tibial posterior slope, and the rotational angles of both the femoral components were measured using three-dimensional computed tomography. LJG at 0° of flexion and correction of tibial posterior slope showed a positive correlation with PROMs. In contrast, LJG at 90° of flexion, correction of FTA, and femoral component rotational angle were negatively correlated with PROMs. The area under the curve (AUC) for MJG at 0° was 0.706, with a cut-off value of 1.6 mm identified using the Youden index.

This study evaluated joint-specific and generic patient-reported outcome measures (PROMs) after total hip arthroplasty (THA) and total ankle arthroplasty (TAA) in matched cohorts, while evaluating implant survivorship and 90-day hospital use.

Primary THA and TAA patients from 1 January 2015 to 1 January 2023 with minimum one-year follow-up were retrospectively reviewed. After applying exclusion criteria, 2,092 THAs and 478 TAAs were analyzed. Demographics, pre- and postoperative PROMs, revision surgeries, emergency department visits, and readmissions were collected. THA and TAA patients were then propensity score matched at a 2:1 ratio for age, sex, race, BMI, American Society of Anesthesiologists classification, and comorbidities, resulting in a final cohort of 844 THAs and 455 TAAs for comparison.

Median preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference (PI) scores between THA and TAA were calculated (66.0 (IQR 62.0 to 70.0) vs 65.0 (IQR 62.0 to 70.0); p = 0.276), and both showed improvement at six weeks. However, THA patients exhibited lower median PROMIS PI scores at one year (53.0 vs 54.0; p = 0.009), as well as a greater median decrease in PROMIS PI from preoperative to one year (-13.0 (IQR -20.0 to -8.0) vs -12.0 (IQR -18.0 to -7.0); p = 0.023). Median preoperative PROMIS physical function (PF) was worse in THA patients (36.0 (IQR 32.0 to 40.0) vs 37.0 (IQR 33.0 to 40.0); p = 0.031), but showed greater median improvement compared to TAA patients at both six weeks (7.0 (IQR 3.0 to 12.0) vs 3.0 (IQR -2.0 to 9.0); p < 0.001) and one year (11.0 (IQR 6.0 to 17.0) vs 8.0 (IQR 4.5 to 13.0); p < 0.001). Preoperative PROMIS depression scores were similar and improved similarly in both groups. Joint-specific PROMs improved in both cohorts.

Patients undergoing THA or TAA experienced improvements in joint-specific PROMs postoperatively which translated to improved generic PROMs across both joints. Generic PROMs can be a useful tool to compare outcomes in THA and TAA. Results suggest that higher functional scores may be achieved sooner in THA.

Total knee arthroplasties (TKAs) exhibit an 8 to 30% risk of suboptimal outcomes, resulting in persistent symptoms, individual morbidity, and revision surgery, prompting a contemporary focus on risk reduction and outcome improvement. This study introduces hierarchical cluster analysis as a way of preoperatively assessing the likelihood of success/failure of TKA based on several patient-reported outcome measures (PROMs), which have been analyzed both intact and with component questions as individual variables.

The study utilized data on 1,433 TKAs from The Miriam Hospital's Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement registry. Outcomes are expressed as Knee Injury and Osteoarthritis Outcome Score pain and function scores. Criteria for success/failure were developed with an integrative, anchor-based, minimum clinically important difference. Preoperative and postoperative PROMs were studied by cluster analysis.

There were three sequential cluster analyses that revealed clusters of patients, based upon preoperative patient responses that were predictive of surgical outcomes. Clusters varied most significantly in their responses to individual component questions of preoperative PROMs. Extracting and combining the clinically meaningful patient-reported component questions yielded a new, and clinically relevant, outcome measure that has the potential to preoperatively predict postoperative outcomes of TKA.

In contrast to a single medical, psychological, or social variable, cluster analysis offers the opportunity to develop a whole-patient profile that reflects the contextual interactions of sociodemographic and clinical variables in predicting outcomes. In the context of determining clinical meaningfulness, cluster analysis has one of its major strengths.

Quality of care in total knee arthroplasty (TKA) between implants was assessed using a novel composite outcome measure, early optimal recovery (EOR), to indicate ideal clinical outcomes and minimal healthcare resource utilization.

Patients that underwent primary TKA in the study group (ATTUNE® Knee System) or control group (LCS® COMPLETE Knee System) were included in this retrospective, single-center study. EOR was defined as no complications, no readmissions, no extra outpatient visits, ≤ 48 h length of hospital stay (LOS), and restored range of motion and pain perception at 3-month follow-up. Multivariate logistic regression was used to compare EOR between the study and control groups. Results were adjusted for differences in baseline characteristics and are presented with 95% confidence intervals (CI). Data were collected from a specialized clinic for elective surgeries in the Netherlands, between January 2017 and December 2020.

A total of 566 patients (62.4% female, mean age 67 years) were included for analysis; 185 patients (32.7%) underwent TKA in the study group. Compared to the control group, patients in the study group had greater probability of achieving EOR (65.8% [95% CI: 55.1-75.2] vs. 38.9% [95% CI: 32.8-45.3]; p < 0.001), a LOS ≤ 48 h (77.2% [95% CI: 67.7-84.5] vs. 61.4% [95% CI: 54.7-67.7]; p < 0.05), and ideal pain perception at 3-month follow-up (93.3% [95% CI: 85.7-97.0] vs. 78.2% [95% CI: 71.0-83.9]; p < 0.05).

The study group was associated with a greater probability of achieving EOR versus the control group, suggesting improved quality of care.

Evaluate the effectiveness of genicular nerve radiofrequency ablation (GNRFA) for chronic knee pain using the Patient-Reported Outcomes Measurement Information System Global Health, Physical Health score (PROMIS-GH-PH).

Patients who underwent GNRFA at a tertiary academic center were identified by CPT code query and contacted for consent. Demographic, clinical, and procedural characteristics were collected from the electronic medical record of participants with baseline PROMIS-GH-PH scores. Outcome data were collected by standardized telephone survey. Treatment success was defined as a ≥2.3-point improvement in PROMIS-GH-PH score (the minimal clinically important difference [MCID]). Predictor variables of PROMIS score change were evaluated using univariate and multivariate linear regression analyses.

32 patients (65.6 % female; 63.7 ± 10.7 years of age) met eligibility criteria and consented to be included in the study. In this cohort, 56.3 % (18/32; 95 % CI: 37.7-73.6) of patients reported improvement ≥ MCID on PROMIS-GH-PH at a mean follow-up time of 21.5 ± 10.6 months. Linear regression analysis demonstrated that patients who never smoked and those with a Kellgren-Lawrence (KL) osteoarthritis grade of 4 had significantly greater PROMIS-GH-PH score improvements at follow-up compared to current or former smokers and patients with KL grades of 0-3, respectively.

In this real-world cross-sectional cohort study, over 56 % of participants experienced improvment ≥ MCID on PROMIS-GH-PH after undergoing GFRNA for chronic knee pain. Non-smoking status and radiographically severe osteoarthritis were associated with greater PROMIS-GH-PH score improvements from baseline.

Anterior knee pain and other patello-femoral (PF) complications frequently limit the success of total knee arthroplasty as the final treatment of end stage osteoarthritis. However, knowledge about the in-vivo loading conditions at the PF joint remains limited, as no direct measurements are available. We hypothesised that the external knee flexion moment (EFM) is highly predictive of the PF contact forces during activities with substantial flexion of the loaded knee.

Six patients (65-80 years, 67-101 kg) with total knee arthroplasty (TKA) performed two activities of daily living: sit-stand-sit and squat. Tibio-femoral (TF) contact forces were measured in vivo using instrumented tibial components, while synchronously internal TF and PF kinematics were captured with mobile fluoroscopy. The measurements were used to compute PF contact forces using patient specific musculoskeletal models. The relationship between the EFM and the PF contact force was quantified using linear regression.

Mean peak TF contact forces of 1.97-3.24 times body weight (BW) were found while peak PF forces reached 1.75 to 3.29 times body weight (BW). The peak EFM ranged from 3.2 to 5.9 %BW times body height, and was a good predictor of the PF contact force (R 2 = 0.95 and 0.88 for sit-stand-sit and squat, respectively).

The novel combination of in vivo TF contact forces and internal patellar kinematics enabled a reliable assessment of PF contact forces. The results of the regression analysis suggest that PF forces can be estimated based solely on the EFM from quantitative gait analysis. Our study also demonstrates the relevance of PF contact forces, which reach magnitudes similar to TF forces during activities of daily living.

Jehovah's Witness patients refuse blood transfusion because of their religious beliefs making total hip arthroplasty (THA) challenging. This study aims to determine the safety of THA in Jehovah's Witness patients using standard perioperative protocols as well as evaluate the effectiveness of tranexamic acid (TXA) in controlling blood loss.

Databases from two tertiary academic centers were queried from 2003 to 2021 to identify THA patients. Demographics, pre- and postoperative hemoglobin (hgb) and hematocrit (hct) lab values, use of TXA intraoperatively, 90-day postoperative hospital utilization, and need for subsequent revision were extracted. Patients who identified as Jehovah's Witness were then compared to a 3:1 propensity score matched cohort of non-Jehovah's Witness patients. Linear regression analysis assessed the effect of intraoperative TXA on change in hgb from pre- to post-THA and logistic regression was used to assess risk of reaching hgb levels < 8.0 g/dL.

A total of 207 non-Jehovah's Witness patients and 69 Jehovah's Witness patients who underwent THA were analyzed. Both groups were found to have similar preoperative hgb and hct as well as postoperative hgb, hct, and hgb shift. Of the Jehovah's Witness patients 3 (6.4%) patients reached a hgb < 8.0 g/dL. Additionally, a higher proportion of Jehovah's Witness patients receive intraoperative TXA (55 [79.7%]) compared to non-Jehovah's Witness patients (127 [61.4%]) (p = 0.01; SMD = 0.41). Logistic regression analysis found that Jehovah's Witness did not have greater odds of reaching a hgb < 8.0 g/dL (OR = 1.03 [0.95, 1.10]; p = 0.49) and that patient who received intraoperative TXA had decreased odds of reaching a hgb < 8.0 (OR = 0.87 [0.80, 0.95]; p = 0.001). Multivariate linear regression found that intraoperative TXA was also associated with a smaller decrease in hgb from pre- to post-THA (β = 0.69 [0.16, 1.22]; p = 0.01). Overall, Jehovah's Witness patients had excellent revision-free (97% [93%, 100%]) and infection-free (99% [96%, 100%]) survival at 7 years.

Although Jehovah's Witness patients refuse transfusion, THA can be performed safely in these patients with excellent implant survivorship by optimizing preoperative hgb levels and utilizing intraoperative TXA.

Level III Evidence.

We report a case of failure of the femoral and tibial components due to anterior cruciate ligament (ACL) injury after robotic-assisted bicruciate-retaining total knee arthroplasty. A 70-year-old woman with osteoarthritis underwent robotic-assisted bicruciate-retaining total knee arthroplasty. At 8 months after surgery, persistent knee pain and swelling of the knee joint were noted after fall in knee. We diagnosed a failure between the femoral and tibial components following an ACL injury. Proximal ACL injury and spin out of ultra-high molecular weight polyethylene were confirmed. We selected a constrained condylar knee prosthesis due to large bone attribution after femoral and tibial component removal. Postoperative three-dimensional computed tomography images suggested that excessive internal rotational alignment of the tibial component caused stress on the ACL.

Total knee arthroplasty (TKA) has consistently demonstrated lower patient satisfaction compared to total hip arthroplasty (THA). However, prior investigations failed to account for the patients' demographic characteristics. This study aimed to conduct a comparative analysis of patient-reported outcomes between TKA and THA while adjusting for patient background.

A total of 326 primary TKAs and 259 THAs conducted at a single center were assessed using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores preoperatively and at 3 months, 1 year, and 2 years postoperatively. Notably, TKA patients exhibited advanced age and higher body mass index (BMI) than their THA counterparts. To mitigate the impact of these differences, we employed propensity score-matched data, adjusting for background characteristics such as age, gender, BMI, and diagnosis.

THA consistently demonstrated significantly superior WOMAC total, pain, and stiffness scores compared to TKA at 3 months, 1 year, and 2 years postoperatively. Nevertheless, no statistically significant disparity in WOMAC physical function scores was observed between the two groups at 3 months and 1 year postoperatively in the matched data (3 months, p = 0.131; 1 year, p = 0.269).

In contrast to earlier findings, our analysis of propensity score-matched data revealed no significant differences in WOMAC physical function scores between the TKA and THA groups at 3 months and 1 year postoperatively. The distinctive background factors observed in patients undergoing TKA and THA, notably advanced age and higher BMI, coupled with the delayed improvement timeline in TKA's WOMAC scores compared to that of THA, have the potential to impact patient-reported outcomes. Consequently, clinicians should be mindful of the potential impact of patient background on variations in patient-reported outcome measures following total joint arthroplasty.

This study investigated the impact of total knee arthroplasty (TKA) on the alignment of the ankle joint, focusing on changes in coronal alignment of both ankles.

This retrospective study, conducted at our hospital, included 64 patients older than 70 years who underwent TKA for varus knee osteoarthritis (OA). Using full-length standing radiographs of both lower extremities taken preoperatively and 6 months postoperatively, we assessed ankle OA grading based on the Takakura-Tanaka classification and measured mechanical hip-knee-ankle (mHKA) and the tibiotalar angle (TTA) on both the surgical and contralateral side. Additionally, we examined the impact of ankle OA on postoperative clinical scores, the Knee injury and Osteoarthritis Outcome Score, following TKA.

Based on the classification, ankle OA stage 2 or higher was present in 13 cases on the surgical side and 13 cases on the contralateral side. On the surgical side, mHKA changed from 12.2 to 1.8 degrees varus (P < .001) and TTA from 1.7 to 1.0 degrees varus (P = .002). On the contralateral side, mHKA changed from 4.0 to 5.4 degrees varus (P = .04), and TTA from 2.7 to 3.0 degrees varus (P < .001). In ankle OA stage 2 or higher patients, contralateral TTA changed from 5.2 to 6.5 degrees varus (P < .001) and unchanged in stage 1 patients. Ankle OA stage 2 or higher patients had worse ADL outcomes than stage 1 patients (score: 67.2 and 78.3, respectively, P = .03).

This study suggests an apparent interrelationship between knee and ankle OA and the potential negative influence of TKA on ankle OA.

Total joint arthroplasty (TJA) is an effective treatment for end-stage osteoarthritis, but postoperative pain has been poorly managed. The purpose of this study was to (1) assess how much narcotic medication was prescribed after TJA; (2) assess if patients were satisfied with their pain management; (3) compare these same data between total hip arthroplasty (THA)/total knee arthroplasty (TKA); (4) compare these same data between preoperative opioid users/opioid-naïve patients.

An IRB-approved prospective study was conducted at a US academic joint replacement practice. Patients were evaluated by an independent observer at three weeks, three months, and six months postoperatively using the Detroit Interventional Pain Assessment (DIPA) scale. Patients verbally rated their pain with their current medication regimen as 0 (no pain), 1 (tolerable pain), or 2 (intolerable pain) on the DIPA scale. Narcotic usage was verified by the Michigan Automated Prescription System (MAPS). Patients were divided into THA, TKA, previously on opioids, and opioid-naïve groups. Provider efficiency scores reflected pain management satisfaction and were calculated as the percentage of patients reporting no pain or tolerable pain.

Out of 200 patients, the percentage of patients using narcotics and their daily usage (MMEs) significantly decreased from 75.5% (27.5 MMEs) at three weeks to 42.9% (5.3 MMEs) at six months (P < 0.001). In 80% of patients, narcotics taken at six months were prescribed by outside providers. Significantly fewer patients used narcotics at six months for THA (15.4%) compared to TKA (52.7%) (P < 0.021). There was a significant difference in daily narcotic usage between patients who took narcotics preoperatively (22.9 MMEs) and opioid-naïve ones (13.4 MMEs) (P < 0.001). Provider efficiency scores were best at three weeks (76.6%) and three months (70%) but declined at six months (57.2%).

Narcotic tapering practices were observed as postoperative daily narcotic intake decreased across six months. However, outside providers prescribed 80% of narcotics at six months, necessitating a better-coordinated practice with surgeons. Patients taking preoperative narcotics experienced higher daily MME requirements than their opioid-naïve counterparts. In terms of the percentage of patients on narcotics, THA is a better procedure for tapering patients off narcotics by six months.

Access to care varies between countries. It is theorized that income-based disparities in access may be reduced in countries with universal health insurance relative to the United States, but data are currently limited. We hypothesized that income-based differences in total hip arthroplasty (THA) utilization and outcomes would be larger in the United States than in Canada.

We retrospectively compared all patients undergoing THA from 2012 to 2018 in Pennsylvania, the United States, and Ontario, Canada. We compared age-standardized and sex-standardized per-capita THA utilization in the United States and Canada overall and across different income strata, where income strata were defined by neighborhood income quintile. We also examined income-based differences in rates of 1-year revision, 90-day mortality, and 90-day readmission.

Overall THA utilization per 10,000 people per year was higher across all income groups in Pennsylvania compared with Ontario (15.1 versus 8.8, P < 0.001 in lowest-income quintile; 21.4 versus 12.6, P < 0.001 in highest-income quintile). Income-based differences in utilization in the highest-income vs lowest-income quintile groups were greater in Ontario (43.2%) than Pennsylvania (41.7%). The adjusted odds for the lowest-income group compared with the highest-income group of 1-year revision were greater in Ontario compared with Pennsylvania ( P = 0.03), and risk of 90-day mortality and 90-day readmission was similar between the regions.

Income-based differences in THA utilization were more notable in Ontario than in Pennsylvania. In addition, patients in low-income communities in Ontario were at equal or greater risk relative to high-income community patients for adverse outcomes compared with patients in Pennsylvania. Income-based disparities in THA utilization and outcomes were smaller in the United States than in Canada, in contrast to what might be expected.

III.

GaitSmart (GS) is a sensor-based digital medical device that can be used with the integrated app vGym to provide a personalised rehabilitation programme for older people undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). This study aimed to determine whether the GS intervention used in the rehabilitation of older people undergoing THA or TKA is potentially cost-effective compared to the current standard of care (SoC).

Decision-analytic modelling was conducted to estimate the cost-effectiveness over a seventeen-week time horizon from an NHS perspective. UK clinical and cost data from the GaitSmart randomised clinical trial was used to obtain the input parameters, and a sensitivity analysis was performed to address uncertainties.

Over a seventeen-week time horizon, GS incurred cost savings of GBP 450.56 and a 0.02 gain in quality-adjusted life years (QALYs) compared to the SoC. These results indicate that GS is the dominant intervention because the device demonstrated greater effectiveness and lower costs. Probabilistic sensitivity analyses confirm the robustness of our results.

GS appears to offer short-term efficiency benefits and demonstrates cost-effectiveness for the improvement in gait in people undergoing THA or TKA, compared to the SoC.

The aim of this study was to investigate the factors affecting patient-reported outcomes after bicruciate-stabilized total knee arthroplasty (BCS TKA) in patients.

We retrospectively examined 122 knees with primary varus knee osteoarthritis that underwent BCS TKA. This study analyzed preoperative, intraoperative, and postoperative predictors of patient satisfaction and persistent postsurgical pain following BCS TKA at 1 year after surgery. We evaluated persistent postsurgical pain using Knee Injury and Osteoarthritis Outcome Score (KOOS) pain subscale and patient satisfaction using a visual analog scale.

The univariate analysis showed a significant negative correlation between the KOOS pain subscale and three factors: the preoperative central sensitization inventory (CSI) score, medial joint laxity at 90° flexion, and acute postsurgical pain. Patient satisfaction was significantly positively correlated with lateral joint laxity at 90° flexion and postoperative extension angle. Acute postsurgical pain had a significant negative correlation with patient satisfaction. The multiple regression analysis revealed preoperative CSI score and medial joint laxity at 90° flexion influenced patients' KOOS pain subscale responses. Only lateral joint laxity at 90° flexion had an impact on patient satisfaction.

The acquisition of adequate soft tissue balance according to the concept of BCS TKA and preoperative central sensitization syndrome affects the clinical outcomes in BCS TKA.

Total knee arthroplasty (TKA) is an end-stage treatment for knee osteoarthritis that relieves pain and loss of mobility, but patient satisfaction and revision rates require improvement. One cause for TKA revision is joint instability, which may be due to improper ligament balancing. A better understanding of the relationship between prosthesis design, alignment, and ligament engagement is necessary to improve component designs and surgical techniques to achieve better outcomes. We investigated the biomechanical effects of ligament model complexity and ligament wrapping during laxity tests using a virtual joint motion simulator. There was little difference in kinematics due to ligament complexity or ligament wrapping.

Health care professionals use mobile apps to support patients' rehabilitation after total hip or knee arthroplasty. Understanding patient engagement in such mobile health interventions can help tailor these interventions to better support patients.

This study aimed to investigate patient engagement in a mobile app-based arthroplasty rehabilitation program and to investigate the association between patient engagement and their characteristics.

Data were extracted from a pool of 42 participants in the experimental arm of a randomized controlled trial that used a mobile app (WeChat [Tencent Holdings Limited])-based program to support patients' rehabilitation after total hip or knee arthroplasty. The primary outcomes were the number of days the participants accessed the program and completed recommended rehabilitation tasks. Secondary outcomes included data on the participants' posts on a discussion forum, messages sent by the participants, access to the program components, and reading and sharing the program content. Generalized linear models were used to analyze the association between patient engagement and personal characteristics.

The participants reported in a rehabilitation diary accessing the program on a mean of 5.2 (SD 2) days per week and completing recommended rehabilitation tasks on a mean of 6.5 (SD 0.8) days per week. The majority (31/42, 74%) posted on the discussion forum, with a mean of 18.1 (SD 21.2) posts. Most participants (37/42, 88%) sent messages to health care professionals, with a mean of 14 (SD 15.9) messages. The program components were visited for a total of 525 times. The program content was read 898 times and shared 82 times in total. Generalized linear models showed that both primary outcomes, the number of days the participants accessed the program (B=6.46, 95% CI 1.98-15.35; χ21=11.1, P=.001) and the number of days they completed rehabilitation tasks (B=2.65, 95% CI 0.45-5.48; χ21=5.7, P=.02), were positively associated with having a high school education or above. In addition, the number of posts on the discussion forum was positively associated with living with family, having a high school education or above, undergoing total knee arthroplasty, having comorbidities, and the score of self-efficacy but was negatively associated with age. The number of messages sent by the participants was positively associated with having a high school education or above, having comorbidities, and the score of self-efficacy.

Patient engagement in mobile arthroplasty rehabilitation is associated with their education level, cohabitation status, age, type of surgery, presence of comorbidities, and sense of self-efficacy. Program developers can consider these characteristics and use strategies, such as family involvement, in the design of mobile arthroplasty rehabilitation programs to enhance patient engagement in such interventions.

Australian New Zealand Clinical Trials Registry ACTRN12621000867897; https://tinyurl.com/mtdw25fp.

We compared the efficacy and safety of a modified cocktail for postoperative analgesia and early functional rehabilitation in patients undergoing total hip arthroplasty (THA).

Magnesium sulfate and sodium bicarbonate were added to a cocktail of ropivacaine, epinephrine, and dexamethasone. Primary outcome measures were visual analog scale (VAS) pain scores at various intervals after surgery, morphine consumption for rescue analgesia after surgery, and time to first rescue analgesia. Secondary outcomes were hip function after surgery, daily walking distance, quadriceps muscle strength, and the incidence of postoperative adverse reactions.

Morphine consumption was significantly lower in the modified cocktail group than in the control group in the first 24 hours after surgery (6.2 ± 6.0 versus 14.2 ± 6.4 mg, P < .001), as was total morphine consumption (10.0 ± 8.6 versus 19.2 ± 10.1 mg, P < .001). The duration of the first rescue analgesia was significantly prolonged (23.7 ± 10.3 versus 11.9 ± 5.8 mg, P < .001). Morphine consumption was also reduced in the magnesium sulfate and sodium bicarbonate groups over a 24-hour period compared to the control group (P < .001). The modified cocktail group had significantly lower resting VAS pain scores than the control group within 24 hours after surgery (P < .050). The VAS pain scores during movement within 12 hours after surgery were also lower (P < .050). The experimental groups showed better hip range of motion (P < .050) and longer walking distance (P < .050) on the first postoperative day, and levels of inflammatory markers were significantly reduced. The incidence of postoperative adverse reactions was similar among the 4 groups.

The modified cocktail with a new adjuvant can prolong the duration of postoperative analgesia, reduce the dosage of rescue analgesics, and accelerate early postoperative functional recovery in patients undergoing THA.

Unanticipated failure to discharge home (failure to launch, FTL) following scheduled same-day discharge (SDD) total joint arthroplasty (TJA) is problematic for the surgical facility with respect to staffing, care coordination, and reimbursement concerns. The aim of this study was to review rates, etiologies, and contributing factors for FTL in SDD TJA at an inpatient academic medical center.

All patients who underwent primary TJA between February 2021 and February 2023 were retrospectively reviewed. Of those scheduled for SDD, risk factors for FTL were compared with successful SDD. Readmission and emergency department (ED) visits were compared with historical cohorts. There were 3,093 consecutive primary joint arthroplasties performed, of which 2,411 (78%) were scheduled for SDD.

Overall, SDD was successful in 94.2% (n = 2,272) of patients who had an FTL rate of 5.8%. Specifically, SDD was successful in 91.4% with total hip arthroplasty, 96.0% with total knee arthroplasty, and 98.6% with unicompartmental knee arthroplasty. Factors that significantly increased the risk of FTL included general anesthesia versus spinal anesthesia (P < .0001), later surgery start time (P < .0001), longer surgical time (P = .0043), higher estimated blood loss (P < .0001), women (P = .0102), younger age (P = .0079), and lower preoperative mental health patient-reported outcomes scores (P = .0039). Readmission and ED visit rates were not higher in the SDD group when compared to historical controls (P = .6830).

With a comprehensive multidisciplinary approach dedicated to improving SDDs at an academic medical center, we have seen successful SDD in nearly 80% of primary TJA, with an FTL rate of 5.8%, and no increased risk of readmission or ED visits. Without adding many personnel, hospital recovery units, or other resources, simple interventions to help decrease FTL have included enhanced preoperative education and expectation settings, improved perioperative communications, reallocating personnel from the inpatient to the outpatient setting, the use of short-acting spinal anesthetics, and earlier scheduled surgery times.

Total hip and knee arthroplasty (THA/TKA) are reliable surgical procedures for alleviating pain and optimizing function. Spinal fusion has also been shown to be beneficial, however the comparative benefit of THA/TKA to lumbar spinal fusion is incompletely understood.

This study analyzed a single-center database of patients who underwent primary lumbar spinal fusion, elective primary TKA, or THA. Patient-reported outcome measures (PROMs) included Veterans-Rand (VR12) Physical and Mental Component Score (PCS/MCS) for TKA/THA and PROMIS (Patient-Reported Outcomes Measurement Information System) Global Mental and Physical Health (GPH/GMH) for spinal fusion.

A total of 356 patients who underwent TKA, 290 who underwent THA, and 125 who underwent spinal fusion were included. Joint replacement patients were older, with higher body mass index in the TKA group. Spine patients had a lower improvement in physical health than the joint patients (TKA: 9.4 ± 11.2, THA: 15.2 ± 11.2, Spine: 6.2 ± 8.7, P < 0.001) and a lower proportion of patients reaching the minimal clinically important difference (MCID). Spine patients had higher GMH improvements compared with TKA patients (TKA: -1.1 ± 10.7, THA: 1.1 ± 11.9, Spine: 1.8 ± 8.4, P = 0.009) and the highest proportion of patients reaching the MCID.

Spinal fusion, total knee arthroplasty, and total hip arthroplasty all significantly improved PROMs at 1-year follow-up. At baseline, spinal fusion patients had better physical function scores and worse mental health scores compared with joint arthroplasty patients, while spinal fusion resulted in mean smaller gains in patient reported physical function and higher gains in patient reported mental health function compared with arthroplasty.

Our study addresses the lack of consensus on measuring leg length discrepancy (LLD) after total hip arthroplasty (THA). We will assess the inter-observer variability and correlation between the five most commonly used LLD methods and investigate the use of trigonometric principles in overcoming the limitations of current techniques.

LLD was measured on postoperative AP pelvic radiographs using five conventional methods. CT images created a 3D computer model of the pelvis and femur. The resulting models were projected onto a 2D, used to measure LLD by the five methods. The measurements were evaluated via Taguchi analysis, a statistical method identifying the process's most influential factors. The approach was used to assess the new trigonometric method.

Conventional methods demonstrated poor correlation. Methods referenced to the centers of the femoral heads were insensitive to LLD originating outside the acetabular cup. Methods referencing either the inter-ischial line or the inter-obturator foramina to the lesser trochanter were sensitive to acetabular and femoral components. Trigonometry-based measurements showed a higher correlation.

Our results underscore clinicians' need to specify the methods used to assess LLD. Applying trigonometric principles was shown to be accurate and reliable, but it was contingent on proper radiographic alignment.

This study evaluated blood glucose (BG), creatinine levels, metabolic issues, length of stay (LOS), and early postoperative complications in diabetic primary total knee arthroplasty (TKA) patients. It examined those who continued home oral antidiabetic medications and those who switched to insulin postoperatively. The hypothesis was that continuing home medications would lead to lower BG levels without metabolic abnormalities.

Patients who had diabetes who underwent primary TKA from 2013 to 2022 were evaluated retrospectively. Diabetic patients who were not on home oral antidiabetic medications or who were not managed as an inpatient postoperatively were excluded. Patient demographics and laboratory tests collected preoperatively and postoperatively as well as 90-day emergency department visits and 90-day readmissions, were pulled from electronic records. Patients were grouped based on inpatient diabetes management: continuation of home medications versus new insulin coverage. Acute postoperative BG control, creatinine levels, metabolic abnormalities, LOS, and early postoperative complications were compared between groups. Multivariable regression analyses were performed to measure associations.

A total of 867 primary TKAs were assessed; 703 (81.1%) patients continued their home oral antidiabetic medications. Continuing home antidiabetic medications demonstrated lower median maximum inpatient BG (180.0 mg/dL versus 250.0 mg/dL; P < .001) and median average inpatient BG (136.7 mg/dL versus 173.7 mg/dL; P < .001). Logistic regression analyses supported the presence of an association (odds ratio = 17.88 [8.66, 43.43]; P < .001). Proportions of acute kidney injury (13.5 versus 26.7%; P < .001) were also lower. There was no difference in relative proportions of metabolic acidosis (4.4 versus 3.7%; P = .831), LOS (2.0 versus 2.0 days; P = .259), or early postoperative complications.

Continuing home oral antidiabetic medications after primary TKA was associated with lower BG levels without an associated worsening creatinine or increase in metabolic acidosis.

Retrospective Cohort Study.

Patients often prefer one knee over the other following staged bilateral total knee arthroplasty (BTKA). Our study compared patient-reported outcomes scores of each knee following BTKA and identified factors that may contribute to the identified discrepancies.

All patients who underwent staged BTKA between July 2014 and August 2022 were identified. The patient-reported outcomes were collected preoperatively and at 2 weeks, 6 weeks, 1 year, and 2 years postoperatively. Each knee's results were compared using paired t-tests and McNemar tests. Preoperative Kellgren-Lawrence Grade (KLG), postoperative range of motion (ROM), reoperation rates, and manipulations under anesthesia (MUAs) were collected. Results were stratified based on time between TKAs (< 3 months, 3 to 12 months, 1 to 2 years, and > 2 years).

There were 911 patients who underwent staged BTKA, with a mean 4.1-year follow-up. The ROM, patient satisfaction, MUAs, and reoperations were not significantly different between knees. Comparing the KLG of the first and second knees, 71% had the same KLG for both knees, 21% had a lower KLG, and 7% of the second knees had a higher KLG. The first knee had greater pain reduction (-10.6 at 2 weeks, -27.4 at 6 weeks) compared to the second (9.3 at 2 weeks, -8.1 at 6 weeks) (P < .0001) and better improvement in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) score (8.5 at 2 weeks, 16.9 at 6 weeks) compared to the second (-5.8 at 2 weeks, 5.0 at 6 weeks) (P < .0001). The 1-year outcomes between first and second knees, or recovery curves, were not different when stratifying by time between TKAs.

The second knee in a staged BTKA has less delta improvement in KOOS JR and pain scores at early follow-up, likely due to higher starting KOOS JR and Patient-Reported Outcomes Measurement Information System scores, despite similar final patient satisfaction and clinical outcome measures. Lower KLG in the second total knee arthroplasty (TKA) may contribute to these findings. An MUA after the first TKA is highly predictive of an MUA after the second TKA.

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the mainstays of multimodal pain management. While effective for acute pain control, recent pre-clinical evidence has raised concerns regarding an association between NSAIDs and chronic pain and potential opioid use. Our objective was to explore the association between peri-operative use of prescription NSAIDs and the need for continued opioid prescriptions lasting 90-180 days in previously opioid-naïve patients undergoing total knee arthroplasty. A database of health claims in the USA was used to identify all opioid-naïve adult patients who underwent primary knee arthroplasty between January 2010 and October 2021. We evaluated the magnitude of association between peri-operative prescription NSAID claims and claims for opioids at 90 days postoperatively using multivariable logistic regression models. Secondary outcomes included: the magnitude of association between peri-operative NSAID prescription and claims for opioids at 180 days postoperatively; and identifying other potential factors associated with opioid claims at 90 days postoperatively. After risk adjustment using multivariable logistic regression models in the 789,736-patient cohort, the adjusted odds ratio (95%CI) for a continuous claim of opioids at 90 and 180 days postoperatively among patients with a peri-operative NSAID prescription within 30 days was 1.32 (1.30-1.35), p < 0.001; and 1.12 (1.10-1.15), p < 0.001, respectively. This estimate of effect remained robust at 90 days after accounting for known potential confounders, including pre-existing knee pain and acute postoperative pain severity. Similar analysis of other pain medications (e.g. paracetamol) did not detect such an association. This population-based cohort study suggests that peri-operative prescription NSAID use may be associated with continued opioid prescription claims at 90 and 180 days after knee arthroplasty, even after adjusting for other observed covariates for continuous opioid claims. These novel findings can inform clinical decision-making for post-surgical pain management, risk-benefit discussions with patients and future research.

This study sought to determine if the use of tranexamic acid (TXA) in preexisting thromboembolic risk patients undergoing total joint arthroplasty (TJA) was linked to an increased risk of death or postoperative complications.

We conducted a comprehensive search for studies up to May 2023 in PubMed, Web of Science, EMBASE, and the Cochrane Library. We included randomized clinical trials, cohort studies, and case-control studies examining the use of TXA during TJA surgeries on high-risk patients. The Cochrane Risk of Bias instrument was used to gauge the excellence of RCTs, while the MINORS index was implemented to evaluate cohort studies. We used mean difference (MD) and relative risk (RR) as effect size indices for continuous and binary data, respectively, along with 95% CIs.

Our comprehensive study, incorporating data from 11 diverse studies involving 812 993 patients, conducted a meta-analysis demonstrating significant positive outcomes associated with TXA administration. The findings revealed substantial reductions in critical parameters, including overall blood loss (MD = -237.33; 95% CI (-425.44, -49.23)), transfusion rates (RR = 0.45; 95% CI (0.34, 0.60)), and 90-day unplanned readmission rates (RR = 0.86; 95% CI (0.76, 0.97)). Moreover, TXA administration exhibited a protective effect against adverse events, showing decreased risks of pulmonary embolism (RR = 0.73; 95% CI (0.61, 0.87)), myocardial infarction (RR = 0.47; 95% CI (0.40-0.56)), and stroke (RR = 0.73; 95% CI (0.59-0.90)). Importantly, no increased risk was observed for mortality (RR = 0.53; 95% CI (0.24, 1.13)), deep vein thrombosis (RR = 0.69; 95% CI (0.44, 1.09)), or any of the evaluated complications associated with TXA use.

The results of this study indicate that the use of TXA in TJA patients with preexisting thromboembolic risk does not exacerbate complications, including reducing mortality, deep vein thrombosis, and pulmonary embolism. Existing evidence strongly supports the potential benefits of TXA in TJA patients with thromboembolic risk, including lowering blood loss, transfusion, and readmission rates.

Patients undergo total joint arthroplasty to improve function and resolve pain. Patient-reported outcome measures (PROMs) are often sought to determine the success of total joint arthroplasty but are time-consuming and patient response rates are often low. This study sought to determine whether pain numeric rating scores (NRSs) were associated with PROMs and objective mobility outcomes.

This is a retrospective review of data in patients who utilized a smartphone-based care management application prior to and following total joint arthroplasty. NRS, Hip Disability and Osteoarthritis Outcome Score, Joint Replacement and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, and objective mobility data (step counts, gait speed, and gait asymmetry) were collected preoperatively and at 30 and 90 days postoperatively. Quantile regression was performed to evaluate the correlations between NRS and PROMs.

Total knee arthroplasty patients reported higher NRS than total hip arthroplasty patients postoperatively. NRS was significantly correlated with gait speed preoperatively and at 30 and 90 days postoperatively on quantile regression. Gait asymmetry was significantly associated with NRS at 30 days postoperatively. Regression results suggested significant correlations between NRS and PROMs scores; Hip Disability and Osteoarthritis Outcome Score, Joint Replacement, -0.46 (95% confidence interval: -0.48 to -0.44, P < .001) and Knee Injury and Osteoarthritis Outcome Score, Joint Replacement, -0.38 (95% confidence interval: -0.40 to -0.36, P < .001).

NRS is correlated with both objective and subjective measures of function in patients undergoing arthroplasty. Simple pain ratings may be a valid measurement to help predict functional outcomes when collection of traditional PROMs is not feasible.

When evaluating the results of clinical research studies, readers need to know that patients perceive effect sizes, not p values. Knowing the minimum clinically important difference (MCID) and the patient-acceptable symptom state (PASS) threshold for patient-reported outcome measures helps us to ascertain whether our interventions result in improvements that are large enough for patients to care about, and whether our treatments alleviate patient symptoms sufficiently. Prior studies have developed the MCID and PASS threshold for the Hip Disability and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) and Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR) anchored on satisfaction with surgery, but to our knowledge, neither the MCID nor the PASS thresholds for these instruments anchored on a single-item PASS question have been described.

(1) What are the MCID (defined here as the HOOS/KOOS JR change score associated with achieving PASS) and PASS threshold for the HOOS JR and KOOS JR anchored on patient responses to the single-item PASS instrument? (2) How do patient demographic factors such as age, gender, and BMI correlate with MCID and PASS thresholds using the single-item PASS instrument?

Between July 2020 and September 2021, a total of 10,970 patients underwent one primary unilateral THA or TKA and completed at least one of the three surveys (preoperative HOOS or KOOS JR, 1-year postoperative HOOS or KOOS JR, and 1-year postoperative single-item anchor) at one large, academic medical center. Of those, only patients with data for all three surveys were eligible, leaving 13% (1465 total; 783 THAs and 682 TKAs) for analysis. Despite this low percentage, the overall sample size was large, and there was little difference between completers and noncompleters in terms of demographics or baseline patient-reported outcome measure scores. Patients undergoing bilateral total joint arthroplasty or revision total joint arthroplasty and those without all three surveys at 1 year of follow-up were excluded. A receiver operating characteristic curve analysis, leveraging a 1-year, single-item PASS (that is, "Do you consider that your current state is satisfactory?" with possible answers of "yes" or "no") as the anchor was then used to establish the MCID and PASS thresholds among the 783 included patients who underwent primary unilateral THA and 682 patients who underwent primary unilateral TKA. We also explored the associations of age at the time of surgery (younger than 65 years or 65 years and older), gender (men or women), BMI (< 30 or ≥ 30 kg/m 2 ), and baseline Patient-Reported Outcome Measure Information System-10 physical and mental component scores (< 50 or ≥ 50) for each of the MCID and PASS thresholds through stratified analyses.

For the HOOS JR, the MCID associated with the PASS was 23 (95% CI 18 to 31), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 81 (95% CI 77 to 85), with an area under the receiver operating characteristic curve of 0.81. For the KOOS JR, the MCID was 16 (95% CI 14 to 18), with an area under the receiver operating characteristic curve of 0.75, and the PASS threshold was 71 (95% CI 66 to 73) with an area under the receiver operating characteristic curve of 0.84. Stratified analyses indicated higher change scores and PASS threshold for younger men undergoing THA and higher PASS thresholds for older women undergoing TKA.

Here, we demonstrated the utility of a single patient-centered anchor question, raising the question as to whether simply collecting a postoperative PASS is an easier way to measure success than collecting preoperative and postoperative patient-reported outcome measures and then calculating MCIDs and the substantial clinical benefit.

Level III, therapeutic study.

Osteoarthritis (OA) poses a growing challenge for the aging population, especially in the hip and knee joints, contributing significantly to disability and societal costs. Exploring the integration of wearable technology, this study addresses the limitations of traditional rehabilitation assessments in capturing real-world experiences and dynamic variations. Specifically, it focuses on continuously monitoring physical activity in hip and knee OA patients using automated unsupervised evaluations within the rehabilitation process. We analyzed data from 1144 patients who used a mobile health application after surgery; the activity data were collected using the Garmin Vivofit 4. Several parameters, such as the total number of steps per day, the peak 6-minute consecutive cadence (P6MC) and peak 1-minute cadence (P1M), were computed and analyzed on a daily basis. The results indicated that cadence-based measurements can effectively, and earlier, differ among patients with hip and knee conditions, as well as in the recovery process. Comparisons based on recovery status and type of surgery reveal distinctive trajectories, emphasizing the effectiveness of P6MC and P1M in detecting variations earlier than total steps per day. Furthermore, cadence-based measurements showed a lower inter-day variability (40%) compared to the total number of steps per day (80%). Automated assessments, including P1M and P6MC, offer nuanced insights into the patients' dynamic activity profiles.

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

There is a paucity of literature on optimal patterns of daily walking following joint arthroplasty, which are now evaluated with consumer technologies like smartphones, and can enhance our understanding of post-operative mobility. When smartphone-recorded, daily walking patterns are captured, qualities of gait-recovery such as gait speed or symmetry can be analyzed in real-world environments.

Are the daily distribution of walking bouts in the early post-operative period associated with 90-day gait quality measures following hip and knee arthroplasty?

Gait data was collected passively using a smartphone-based care management platform in patients undergoing hip and knee arthroplasty. As recorded via subjects' free-living smartphone-collected gait bouts, data were investigated as a function of the walking session length and were used to create a ratio to the total time logging bouts, representing the fraction of walking performed during a single session per day (aggregation score). Quantile regression was performed to evaluate the association between early walking session lengths or aggregation score at 30 days post-operatively and the gait-sampled speed and asymmetry of walking at 90 days.

In total, 2255 patients provided evaluable data. The walking session length at 30 days was positively associated with 90-day mean gait speed across procedure types where quantile regression coefficients ranged from 0.11 to 0.17. In contrast, aggregation score was negatively associated with gait speed at 90 days, with coefficients ranging from -0.18 to -0.12.

The duration and frequency of walking bouts was associated with recovery of gait speed and symmetry following lower limb arthroplasty. The findings may help clinicians design walking protocols that are associated with improved gait metrics at 3 months.

Acute postsurgical pain (APSP) may persist over time and become chronic. Research on predictors for APSP and chronic postsurgical pain (CPSP) has produced inconsistent results. This observational study aimed to analyze psychological and psychophysical variables associated with APSP and CPSP after total knee or hip arthroplasty, and to explore the role of sex.

Assessments were conducted before surgery, 48 h, and 3 months postsurgery, including questionnaires (sociodemographic, pain related, and psychological) and quantitative sensory testing (QST). Hierarchical linear regression models analyzed potential predictors of APSP and CPSP, and moderation analyses evaluated the role of sex.

The study included 63 participants undergoing total knee (34, 54%) or hip (29, 46%) arthroplasty. Thirty-one (49.2%) were female and 32 (50.8%) were male. APSP (48 h) was associated with impaired conditioned pain modulation (CPM) (β = 0.301, p = 0.019). CPSP (3 months) was associated with being female (β = 0.282, p = 0.029), longer presurgical pain duration (β = 0.353, p = 0.006), knee arthroplasty (β = -0.312, p = 0.015), higher APSP intensity (β = 373, p = 0.004), and impaired CPM (β = 0.126, p = 0.004). In multivariate analysis, these clinical variables were significant predictors of CPSP, unlike sex, and CPM (adj. R 2 = 0.349). Moderation analyses showed that wind-up ratio (WUR) was a significant predictor of APSP in men (WUR × sex: b = -1.373, p = 0.046) and CPM was a significant predictor of CPSP in women (CPM × sex: b = 1.625, p = 0.016).

Specific QST parameters could identify patients at risk for high-intensity APSP and CPSP, with sex as a moderator. This has important clinical implications for patient care, paving the way for developing tailored preventive pain management strategies.

Background and objectives: Our study aimed to assess the learning curve for robot-assisted (RA) total knee arthroplasty (TKA) in our hospital, compare operative times between RA-TKAs and manual TKAs, and assess the early complications rate between the two approaches. Methods: We included 39 patients who underwent RA-TKA and 45 control patients subjected to manual TKA in the same period and operated on by the same surgical staff. We collected demographic and patient-related data to assess potential differences between the two groups. Results: No statistical differences were recorded in regard to age, BMI, sex, Kellgren-Lawrence classification, or limb alignment between patients undergoing RA-TKA and manual TKA, respectively. Three surgeons transitioned from the learning to the proficiency phase in our study after a number of 6, 4, and 3 cases, respectively. The overall operative time for the learning phase was 111.54 ± 20.45 min, significantly longer compared to the average of 86.43 ± 19.09 min in the proficiency phase (p = 0.0154) and 80.56 ± 17.03 min for manual TKAs (p < 0.0001). No statistically significant difference was recorded between the global operative time for the proficiency phase TKAs versus the controls. No major complications were recorded in either RA-TKA or manual TKA groups. Conclusions: Our results suggest that experienced surgeons may adopt RA-TKA using this platform and quickly adapt without significant complications.

Non-English-speaking patients face increased communication barriers when undergoing total joint arthroplasty (TJA). Surgeons may learn or have proficiency in languages spoken among their patients to improve communication. This study investigated the effect of surgeon-patient language concordance on outcomes after TJA. We conducted a single-institution, retrospective review of patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) whose preferred language was not English. Patients were stratified based on whether their surgeon spoke their preferred language (language concordant [LC]) or not (language discordant [LD]). Baseline characteristics, length of stay, discharge disposition, revision rate, readmission rate, and patient-reported outcomes (Knee injury and Osteoarthritis Outcome Score for Joint Replacement [KOOS, JR], Hip disability and Osteoarthritis Outcome Score for Joint Replacement [HOOS, JR], and Patient-Reported Outcomes Measurement Information System [PROMIS]) were compared. A total of 3390 patients met inclusion criteria, with 855 receiving THA and 2535 receiving TKA. Among patients receiving THA, 440 (51.5%) saw a LC provider and 415 (48.5%) saw a LD provider. Those in the LC group had higher HOOS, JR scores at 1 year postoperatively (67.4 vs 49.3, P=.003) and were more likely to be discharged home (77.5% vs 69.9%, P=.013). Among patients receiving TKA, 1051 (41.5%) received LC care, whereas 1484 (58.5%) received LD care. There were no differences in outcome between the LC and LD TKA groups. Patients receiving THA with surgeons who spoke their language had improved patient-reported outcomes and were more commonly discharged home after surgery. Language concordance did not change outcomes in TKA. Optimizing language concordance for patients receiving TJA may improve postoperative outcomes. [Orthopedics. 2023;46(6):334-339.].

The Attune® total knee arthroplasty system was introduced in 2013 to address lingering issues of patient dissatisfaction. However, recent literature reports concerns of early tibial tray debonding. The aim of this study was to compare the incidence of radiolucent lines, survivorship and patient reported outcome-measures between the Attune® system and the well-established Triathlon® system.

This retrospective database review was conducted at a single institution in Cork, Ireland. All primary Attune® (N = 445) and Triathlon® (N = 285) systems implanted between 2015 and 2016 were reviewed. Radiolucent lines were assessed for those with a minimum two-year radiological follow-up (Attune® = 338; Triathlon® = 231). X-rays were taken post op, at 6 months, 2 years and 5 years. Radiolucent lines were documented using the Modern Knee Society Radiographic System. Five-year survival was assessed using Kaplan-Meier analysis with the Log Rank method to determine statistical significance. The Oxford Knee Score and EQ-5D-5L, were collected pre-op, at 6 months, 2 years and 5 years post-operatively and compared using the Kruskal-Wallis Test.

The Attune® had a higher proportion of radiolucent lines at the tibial tray [87.1% (54/62) vs 61.4% (27/44); p = 0.001] and at the implant-cement interface [62.9% (39/62) vs 43.2% (19/44); p = 0.02]. Conversely, the Triathlon® had a higher proportion AT the femur [38.6% (17/44) vs 12.9% (8/62); p = 0.001] and at the cement-bone interface [56.8% (25/44) vs 37.1% (23/62); p = 0.02]. The overall frequency of radiolucent lines was similar in both the Attune® and Triathlon® groups [17.8%, (60/338) vs 17.7%, (41/231); p = 0.49]. There was no difference in revision-free survival analysis at 5 years (Attune® 97.8% vs Triathlon® 95.8%; p = 0.129). The Attune® performed better at 5 years in the Oxford Knee Score [Attune® = 42.6 (SD 5.2) vs Triathlon® = 41 (SD 6.4); p = 0.001] and in the EQ-5D [Attune® = 0.773 (SD 0.187) vs Triathlon® = 0.729 (SD 0.218); p = 0.013]. There was no difference at 5 years in the EQ-VAS [Attune® = 80.4 (SD 13.7) vs Triathlon® = 78.5 (SD 15.3); p = 0.25].

The Attune® system exhibited a higher incidence of  radiolucent lines at the tibial tray. However, this did not lead to decreased survivorship at medium term follow-up compared to the Triathlon®. Furthermore, improvements in patient reported outcomes modestly favoured the Attune® system.

III.

Carbazochrome sodium sulfonate (CSS) is a haemostatic agent. However, its hemostatic and anti-inflammatory effects in patients undergoing total hip arthroplasty (THA) via a direct anterior approach (DAA) are unknown. We investigated the efficacy and safety of CSS combined with tranexamic acid (TXA) in THA using DAA.

This study enrolled 100 patients who underwent primary, unilateral THA through a direct anterior approach. Patients were randomly divided into two groups: Group A used a combination of TXA and CSS, while Group B used TXA only. The primary outcome was total perioperative blood loss. The secondary outcomes were hidden blood loss, postoperative blood transfusion rate, inflammatory reactant levels, hip function, pain score, venous thromboembolism (VTE), and incidence of associated adverse reactions.

The total blood loss (TBL) in group A was significantly lower than in group B. The levels of inflammatory reactants and the rate of blood transfusion were also significantly lower. However, the two groups had no significant differences in intraoperative blood loss, postoperative pain score, or joint function. There were no significant differences in VTE or postoperative complications between the groups.

As a haemostatic agent, CSS combined with TXA can reduce postoperative blood loss in patients undergoing THA via DAA and seems to have an anti-inflammatory effect. Moreover, it did not increase the incidence of VTE or its related complications.

Previous reports using cadaveric knees and musculoskeletal computer simulation have shown that kinematically aligned (KA) total knee arthroplasty (TKA) provides more natural and physiological tibiofemoral kinematic patterns than mechanically aligned (MA) TKA. These reports suggested that the modification of joint line obliquity improve the knee kinematics. This study aimed to determine whether joint line obliquity change the intraoperative tibiofemoral kinematics in TKA candidates with knee osteoarthritis.

Thirty consecutive knees with varus osteoarthritis that underwent TKA using a navigation system were evaluated. Two types of trial components were prepared: (1) MA TKA model: component trial in which articulating surface was parallel to the bone cut surface (2) KA TKA model: the femoral component trial, which mimicked the KA TKA method of Dossett et al. was designed 3° valgus and 3° internal rotation to the femoral bone cut surface, and the tibial component trial was designed 3° varus to the tibial bone cut surface. These two trials were set on the same knees during the operation, and the tibiofemoral rotational kinematics and varus-valgus laxity were measured from 0° to 120° of knee flexion using a navigation system.

The joint gap was 20 ± 2 mm and 3° ± 1° varus in extension and 20 ± 2 mm and 3° ± 1°varus in flexion. The differences in femoral component rotation between KA TKA and MA TKA were not statistically significant for any knee flexion angle. The differences in varus-valgus laxity between KA TKA and MA TKA were also not statistically significant for any knee flexion angle.

Although the degree of joint line obliquity varies widely in various KA TKA methods, this study, which mimicked the method of Dossett et al. showed that the modification of joint line obliquity did not change the tibiofemoral kinematics and stability of the knee joint in TKA candidates with knee osteoarthritis.

Patients undergoing total joint arthroplasty (TJA) often experience preoperative/postoperative sleep disturbances. Although sleep quality generally improves > 6 months after surgery, patterns of sleep in the short-term postoperative period are poorly understood. This study sought to (1) characterize sleep disturbance patterns over the 3-month postoperative period and (2) investigate clinical and sociodemographic factors associated with 3-month changes in sleep.

This retrospective analysis of prospectively collected data included 104 primary elective TJA patients. Patients were administered the PROMIS Sleep Disturbance questionnaire preoperatively and at 2 weeks, 6 weeks, and 3 months postoperatively. Median sleep scores were compared between time points using Wilcoxon signed-rank tests, stratified by preoperative sleep impairment. A multivariable logistic regression model identified factors associated with 3-month clinically improved sleep.

The percentage of patients reporting sleep within normal limits increased over time: 54.8% preoperatively and 58.0%, 62.5%, and 71.8% at 2 weeks, 6 weeks, and 3 months post-TJA, respectively. Patients with normal preoperative sleep experienced a transient 4.7-point worsening of sleep at 2 weeks ( P = 0.003). For patients with moderate/severe preoperative sleep impairment, sleep significantly improved by 5.4 points at 2 weeks ( P = 0.002), with improvement sustained at 3 months. In multivariable analysis, patients undergoing total hip arthroplasty (versus knee; OR: 3.47, 95% CI: 1.06 to 11.32, P = 0.039) and those with worse preoperative sleep scores (OR: 1.13, 95% CI: 1.04 to 1.23, P = 0.003) were more likely to achieve clinically improved sleep from preoperatively to 3 months postoperatively.

Patients experience differing patterns in postoperative sleep changes based on preoperative sleep disturbance. Hip arthroplasty patients are also more likely to experience clinically improved sleep by 3 months compared with knee arthroplasty patients. These results may be used to counsel patients on postoperative expectations and identify patients at greater risk of impaired postoperative sleep.

Retrospective analysis of prospectively collected data.

For the increasing number of working-age patients undergoing total hip or total knee arthroplasty (THA/TKA), return to work (RTW) after surgery is crucial. We investigated the association between occupational class and time to RTW after THA or TKA.

Data from the prospective multicentre Longitudinal Leiden Orthopaedics Outcomes of Osteoarthritis Study were used. Questionnaires were completed preoperatively and six and 12 months postoperatively. Time to RTW was defined as days from surgery until RTW (full or partial). Occupational class was preoperatively assessed and categorized into four categories according to the International Standard Classification of Occupations 2008 (blue-/white-collar, high-/low-skilled). Cox regression analyses were conducted separately for THA and TKA patients. Low-skilled blue-collar work was used as the reference category.

A total of 360 THA and 276 TKA patients, preoperatively employed, were included. Patients were mainly high-skilled (THA 57%; TKA 41%) or low-skilled (THA 24%; TKA 38%) white-collar workers. Six months post-THA, RTW rates were 78% of low-skilled blue-collar workers compared to 83% to 86% within other occupational classes, increasing after 12 months to 87% to 90% in all occupational classes. Six months post-TKA, RTW rates were 58% of low-skilled and 64% of high-skilled blue-collar workers compared to 80% to 89% of white-collar workers, and after 12 months 79% of low-skilled blue-collar workers compared to 87% to 92% within other occupational classes. High-skilled white-collar workers (THA: hazard ratio (HR) 2.12 (95% confidence interval (CI) 1.32 to 3.40); TKA: HR 2.31 (95% CI 1.34 to 4.00)) and low-skilled white-collar workers (TKA: HR 1.82 (95% CI 1.04 to 3.18)) had a higher hazard to RTW within six months postoperatively.

Clear differences existed in time to RTW among both THA and TKA patients in each of the groups studied. These findings may help guide tailored patient-specific information during preoperative consultation and advice postoperatively, as well as to create awareness among workers and their employers.

Intravenous acetaminophen is an integral component of multimodal postoperative pain management. This prospective study aims to assess the efficacy of the repeated administration of intravenous acetaminophen and the impact on postoperative patient satisfaction with postoperative pain management after total knee arthroplasty (TKA). We enrolled 98 patients scheduled for unilateral TKA. Patients were randomly assigned to receive either 1000 mg of intravenous acetaminophen at 6-hour intervals (AAP group) or not to receive intravenous acetaminophen (control group). All patients underwent single-shot femoral nerve block after general anesthesia, as well as intraoperative periarticular infiltration of analgesia prior to implantation. The primary outcome was the postoperative numerical rating scale (NRS) pain score at rest. The NRS score was measured just before the administration of study drugs, immediately after arrival in the ward (time 0), and at 6, 12, 18, 24, and 48 h (time 1 to time 5, respectively) postoperatively. We also evaluated the mean doses of rescue opioid use for 24 h postoperatively. At time 5, the AAP group had significantly improved mean NRS score than controls (3.0 vs. 4.0; P < 0.01). Rescue opioid use was significantly lower in the AAP group for 24 hours compared to controls (0.3 μg vs. 0.9 μg; P < 0.01). Repeated intravenous acetaminophen administration after TKA may provide better analgesia and reduce opioid use.

Total hip (THA) and knee arthroplasty (TKA) are surgical interventions for patients with primary and posttraumatic osteoarthritis. The present clinical investigation compared gender differences in THA and TKA.

Data from 419 patients following primary THA and TKA were collected. The occurrence of systemic and surgery-related complications, the units of blood transfused, and the change in Hb were investigated. Hb was collected preoperatively and at 1, 2, 4 and 7 days postoperatively. Statistical analysis was performed using the software IBM SPSS 28.

There was no significant difference in surgery-related and general complications in men between THA and TKA. A significant difference between THA and TKA in systemic complications in women was observed. No significant difference between THA and TKA in related to surgery-related complications was evidenced. In men, no difference in Hb progression was observed. In women, a significant Hb drop was evidenced (p = 0.03). The rate of blood transfusion units in women was significantly greater in TKA than in THA (p = 0.001). No statistically significant difference was observed in men in the rate of transfusion between THA and TKA.

Perioperative care should be organized differently for women and men. Furthermore, a differentiation between the procedures for each sex could prevent the occurrence of perioperative complicated courses.

Sagittal stability in total knee arthroplasty is achieved through complex processes enabled by prosthetic design and intraoperative soft tissue balancing. This study investigated the effects of preserving medial soft tissue on sagittal stability in bicruciate stabilized total knee arthroplasty (BCS TKA).

This retrospective study included 110 patients who underwent primary BCS TKA. The patients were divided into two groups: 44 TKAs were performed releasing medial soft tissue (CON group), and 66 TKAs were performed preserving medial soft tissue (MP group). We assessed joint laxity using tensor device and anteroposterior translation immediately after surgery using the arthrometer at 30° knee flexion. Propensity score matching (PSM) was performed according to preoperative demographic and intraoperative medial joint laxity, and further comparisons between the two groups were performed.

After PSM analysis, medial joint laxity in the mid-flexion range tended to be smaller in the MP group than in the CONT group, with a significant difference at 60 degrees (CON group: - 0.2 ± 0.9 mm, MP group: 0.8 ± 1.3 mm, P < 0.05). Anteroposterior translation was significantly different between the two cohorts (CON group: 11.6 ± 2.5 mm, MP group: 8.0 ± 3.1 mm, P < 0.001).

This study demonstrated the effects of preserving medial soft tissue on postoperative sagittal stability in BCS TKA. We concluded that this surgical procedure enhances postoperative sagittal stability in the mid-flexion range in BCS TKA.

Difficulty kneeling following total knee arthroplasty (TKA) remains highly prevalent, and has cultural, social, and occupational implications. With no clear evidence of superiority, whether or not to resurface the patella remains debatable. This systematic review examined whether resurfacing the patella (PR) or not (NPR) influences kneeling ability following TKA.

This systematic review was conducted by following PRISMA guidelines. Three electronic databases were searched utilizing a search strategy developed with the aid of a department librarian. Study quality was assessed using MINROS criteria. Article screening, methodological quality assessment and data extraction were performed by two independent authors, and a third senior author was consulted if consensus was not reached.

A total of 459 records were identified, with eight studies included in the final analysis, and all deemed to be level III evidence. The average MINORS score was 16.5 for comparative studies and 10.5 for non-comparative studies. The total number of patients was 24,342, with a mean age of 67.6 years. Kneeling ability was predominantly measured as a patient-reported outcome measure (PROM), with two studies also including an objective assessment. Two studies demonstrated a statistically significant link between PR and kneeling, with one demonstrating improved kneeling ability with PR and the other reporting the opposite. Other potential factors associated with kneeling included gender, postoperative flexion, and body mass index (BMI). Re-operation rates were significantly higher in the NPR cohort whereas PR cohorts had higher Feller scores, patient-reported limp and patellar apprehension.

Despite its importance to patients, kneeling remains not only under-reported but also ill-defined in the literature, with no clear consensus regarding the optimum outcome assessment tool. Conflicting evidence remains as to whether PR influences kneeling ability, and to clarify the situation, large prospective randomized studies are required.