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Williams J, Albuquerque Ii JBD, Nuelle CW, Stannard JP, Cook JL. Impacts of Knee Arthroplasty on Activity Level and Knee Function in Young Patients: A Systematic Review. J Knee Surg 2024; 37:452-459. [PMID: 37714214 DOI: 10.1055/a-2176-4688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
The annual demand for knee arthroplasty has been steadily rising, particularly in younger patients. The primary objective of this systematic review was to determine the impact of knee arthroplasties on knee function and activity levels in young (≤55 years) patients. A PubMed search from inception (1977) to March 2022 to identify eligible studies produced 640 peer-reviewed studies for consideration. A total of 18 studies including 4,186 knee arthroplasties in 3,200 patients (mean patient age at the time of surgery: 47.4 years, range: 18-55 years) were ultimately included for analysis. Mean final follow-up (FFU) duration was 5.8 years (range: 2-25.1 years). Mean FFU improvement in Knee Society Clinical Score was 48.0 (1,625 knees, range: 20.9-69.0), Knee Society Function Score was 37.4 (1,284 knees, range: 20-65). Mean FFU for the Tegner and Lysholm activity scale was 2.8 (4 studies, 548 knees, range: 0.7-4.2); University of California Los Angeles Physical Activity Questionnaire score was 2.8 (3 studies, 387 knees, range: 1.2-5); lower extremity activity scale was 1.84 (529 knees). The available evidence suggest that young patients typically realize sustained improvements in knee function compared to preoperative levels; however, these improvements do not typically translate into a return to desired activity levels or quality of life, and this patient population should expect a higher and earlier risk for revision than their older counterparts. Further research, including robust registry data, is needed to establish evidence-based indications, expectations, and prognoses for outcomes after knee arthroplasty in young and active patients.
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Affiliation(s)
- Jonathan Williams
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - João B de Albuquerque Ii
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Clayton W Nuelle
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, Mizzou Joint and Limb Preservation Center, Missouri Orthopaedic Institute, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James P Stannard
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, Mizzou Joint and Limb Preservation Center, Missouri Orthopaedic Institute, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - James L Cook
- Thompson Laboratory for Regenerative Orthopaedics, Missouri Orthopaedic Institute, University of Missouri, Columbia, Missouri
- Department of Orthopaedic Surgery, Mizzou Joint and Limb Preservation Center, Missouri Orthopaedic Institute, Columbia, Missouri
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Cheng R, Krell EC, Chiu YF, Stimac JD, Heyse TJ, Abdel MP, Figgie MP, Blevins JL. Survivorship and Clinical Outcomes of Primary Total Knee Arthroplasty Performed in Patients 35 Years of Age and Younger. J Arthroplasty 2023; 38:2316-2323.e1. [PMID: 37286054 DOI: 10.1016/j.arth.2023.05.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 05/22/2023] [Accepted: 05/24/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Total knee arthroplasties (TKAs) for patients aged ≤35 years are rare but necessary for patients who have diseases such as juvenile idiopathic arthritis, osteonecrosis, osteoarthritis, and rheumatoid arthritis. Few studies have examined the 10-year and 20-year survivorship and clinical outcomes of TKAs for young patients. METHODS A retrospective registry review identified 185 TKAs in 119 patients aged ≤ 35 years performed between 1985 and 2010 at a single institution. The primary outcome was implant survivorship free of revision. Patient-reported outcomes were assessed at 2 time points: 2011 to 2012 and 2018 to 2019. The average age was 26 years (range, 12 to 35). Mean follow-up was 17 years (range, 8 to 33). RESULTS Survivorship decreased from 84% (95% confidence interval [CI]: 79 to 90) at 5 years to 70% (95% CI: 64 to 77) at 10 years and to 37% (95% CI: 29 to 45) at 20 years. The most common reasons for revision were aseptic loosening (6%) and infection (4%). Risk factors for revision included increasing age at time of surgery (Hazards Ratio [HR] 1.3, P = .01) and use of constrained (HR 1.7, P = .05) or hinged prostheses (HR 4.3, P = .02). There were 86% of patients reporting that their surgery resulted in "a great improvement" or better. CONCLUSION Survivorship of TKAs in young patients is less favorable than expected. However, for the patients who responded to our surveys, TKA demonstrated substantial pain relief and improvement in function at 17-year follow-up. Revision risk increased with older age and higher levels of constraint.
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Affiliation(s)
- Ryan Cheng
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Ethan C Krell
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Yu-Fen Chiu
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Jeffrey D Stimac
- Department of Orthopedic Surgery, Norton Healthcare, Louisville, Kentucky
| | - Thomas J Heyse
- Medical Faculty, Philipps-University of Marburg, Marburg, Germany; Red Cross Hospital, Frankfurt, Germany
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mark P Figgie
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Jason L Blevins
- Department of Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
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Perez B, Koressel J, Cohen JS, Kirchner GJ, Kerbel YE, Lee GC. Why and What Happens to Patients Younger Than 60 Years Who Need Revision Total Knee Arthroplasty? J Arthroplasty 2023; 38:2404-2409. [PMID: 37196731 DOI: 10.1016/j.arth.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND With the increasing number of young patients undergoing primary total knee arthroplasty (TKA), there will be an increase in the number of patients who require revision. While the results of TKA in younger patients are well known, there is little information regarding to the outcomes of revision TKA in this population. The purpose of this study was to evaluate the clinical outcomes in patients <60 years of age undergoing aseptic revision TKA. METHODS We retrospectively reviewed 433 patients undergoing aseptic revision TKA between 2008 and 2019. There were 189 patients <60 years compared to a group of 244 patients >60 years undergoing revision TKA for aseptic failures in terms of implant survivorships, complications, and clinical outcomes. Patients were followed for a mean of 48 months (range, 24 to 149). RESULTS A total of 28 (14.8%) patients less than 60 years of age required repeat revision compared to 25 (10.2%) 60 years or older (odds ratio (OR) 1.94, 95% confidence interval (CI) 0.73-5.22, P = .187). There were no differences regarding postprocedural Patient-Reported Outcomes Measurement Information System (PROMIS) physical health scores (72.3 ± 13.7 versus 72.0 ± 12.0, P = .66) and PROMIS mental health scores (66.6 ± 17.4 versus 65.8. ± 14.7, P = .72), at an average of 32.9 and 30.7 months, respectively. Postoperative infection occurred in 3 (1.6%) patients <60 years of age, while 12 (4.9%) postoperative infections occurred in patients 60 years or older (OR 0.75, 95% CI 0.06-10.2, P = .83). CONCLUSION There were no statistically significant differences in clinical outcomes between patients <60 versus > 60 years of age undergoing aseptic revision TKA.
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Affiliation(s)
- Brian Perez
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph Koressel
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jordan S Cohen
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory J Kirchner
- Department of Orthopaedic Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Yehuda E Kerbel
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gwo-Chin Lee
- Hospital for Special Surgery, New York, New York
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Ismailidis P, Schmid C, Werner J, Nüesch C, Mündermann A, Pagenstert G, Egloff C. Distal femoral osteotomy for the valgus knee: indications, complications, clinical and radiological outcome. Arch Orthop Trauma Surg 2023; 143:6147-6157. [PMID: 37278744 PMCID: PMC10491530 DOI: 10.1007/s00402-023-04923-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 05/21/2023] [Indexed: 06/07/2023]
Abstract
INTRODUCTION The aim of this study was to describe the indications and technical aspects of medial closing and lateral opening distal femoral osteotomy (MCDFO and LODFO) for patients with a valgus knee and to report clinical and radiological outcomes and complications. METHODS Over 6 years, 28 DFOs (22 MCDFO, 6 LODFO) were performed in 22 Patients. In this cohort study, we retrospectively analyzed clinical and radiological outcome measures as well as complications. RESULTS The median (range) age was 47 (17-63) years, height 1.68 (1.56-1.98) m, body mass 80 (49-105) kg, and body mass index (BMI) 27.4 (18.6-37.0) kg/m2. The clinical follow-up was 21 (7-81) months, the need for total or unicompartmental knee arthroplasty (TKA/UKA) and hardware removal was followed up for 59 (7-108) months postoperatively. Preoperatively, hip-knee-ankle angle (HKA, negative values denote varus) was 7.0 (2.0-13.0)°, mechanical lateral distal femoral angle (mLDFA) was 83.7 (79.9-88.2)°, and mechanical proximal tibial angle (MPTA) was 89.0 (86.6-94.5)°. Postoperatively, HKA was -1.3 (-9.0-1.2)° and mLDFA was 90.8 (87.3-97.3)°. The incidence of minor and major complications was 25% and 14%, the incidence of delayed and nonunion was 18% and 4%, respectively. At the last follow-up, 18% of the patients had pain at rest, 25% during activities of daily living, and 39% during physical activity, and 71% were satisfied with the outcome. 7% of the cases received a TKA/UKA, 71% received a hardware removal. CONCLUSION DFO is a reasonable treatment for lateral osteoarthritis in younger patients to avoid disease progression and the need for an UKA/TKA. However, there is a long rehabilitation time, a considerable risk for complications, and a high need for hardware removal. While many patients experienced symptoms at the long-term follow-up, most were satisfied with the outcome. Appropriate patient information is essential. Level of evidence Level IV, Case Series. Trial registration number NCT04382118, clinicaltrials.gov, May 11, 2020.
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Affiliation(s)
- Petros Ismailidis
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland.
| | - Corinna Schmid
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Julika Werner
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Corina Nüesch
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
- Department of Spine Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Annegret Mündermann
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
- Department of Spine Surgery, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Geert Pagenstert
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
- Knee Institute Basel, Clarahof, Clinic of Orthopaedic Surgery, Clarahofweg 19a, 4058, Basel, Switzerland
| | - Christian Egloff
- Department of Orthopaedics and Traumatology, University Hospital Basel, Spitalstrasse 21, 4031, Basel, Switzerland
- Department of Clinical Research, University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
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Diaz CC, Lavoie-Gagne OZ, Knapik DM, Korrapati A, Chahla J, Forsythe B. Outcomes of Distal Femoral Osteotomy for Valgus Malalignment: A Systematic Review and Meta-analysis of Closing Wedge Versus Opening Wedge Techniques. Am J Sports Med 2023; 51:798-811. [PMID: 35156408 DOI: 10.1177/03635465211051740] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Valgus knee deformity increases the risk for lateral articular chondral damage, contributing to earlier onset and accelerated progression of osteoarthritis. Distal femoral osteotomy (DFO) unloads the lateral joint compartment and can be performed using closing wedge (CW) or opening wedge (OW) techniques. PURPOSE To perform a systematic review and meta-analysis for patients with valgus knee deformity undergoing DFO to determine differences in patient-reported outcome measures (PROMs), complications, and survival rates, comparing CW versus OW DFO. STUDY DESIGN Systematic review, Level of evidence, 4. METHODS A literature review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines utilizing PubMed, Cochrane Database, Ovid/MEDLINE, and Scopus. Inclusion criteria consisted of studies reporting outcomes in patients undergoing CW or OW DFO for the treatment of valgus knee deformities with symptomatic lateral compartment pathology with a minimum 2-year follow-up. PROMs and complications were analyzed using random-effects modeling to identify differences in outcomes as a function of surgical technique. Long-term survival data, defined as conversion to total knee arthroplasty, were analyzed using a multiple metaregression model as a function of individual study follow-up time points and surgical technique. RESULTS In total, we included 23 retrospective studies (n = 619 knees), of which 10 studies (n = 271 knees) reported outcomes after CW DFO and 13 studies (n = 348 knees) reported on OW DFO outcomes. Good to excellent clinical outcomes were reported in PROMs when compared with preoperative values with both techniques, while no significant differences between techniques were appreciated on functional Knee Society Scores and Tegner scores. No significant differences were appreciated in the incidence of complications reported in patients undergoing CW (20%) versus OW (33%) DFO (P = .432). Pain requiring hardware removal was the most commonly reported complication in both groups. The survival rate for CW DFO was 81.5% (mean follow-up, 8.8 ± 4.3 years) compared with 90.5% for OW DFO (mean follow-up, 4.5 ± 1.5 years). Multiple metaregression demonstrated that patient follow-up (P < .001) was significantly associated with knee survival, while surgical technique (P = .810) was not a predictor of clinical failure. CONCLUSIONS Both CW and OW DFO techniques were associated with good to excellent clinical outcomes with no significant differences in PROMs based on technique. Pain requiring hardware removal was the most common complication in both techniques, while long-term survivability was found to be a function of follow-up and not surgical technique. Technique selection should be based on shared patient-physician decision making with an emphasis on surgeon preference and technique familiarity.
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Affiliation(s)
| | | | | | | | - Jorge Chahla
- Midwest Orthopaedics at Rush Chicago, Illinois, USA
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Sheridan GA, Cassidy RS, McKee C, Hughes I, Hill JC, Beverland DE. Survivorship of 500 Cementless Total Knee Arthroplasties in Patients Under 55 Years of Age. J Arthroplasty 2022; 38:820-823. [PMID: 36309144 DOI: 10.1016/j.arth.2022.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND With respect to survivorship following total knee arthroplasty (TKA), joint registries consistently demonstrate higher revision rates for both genders in those aged less than 55 years. The present study analyzed the survivorship of 500 cementless TKAs performed in this age group in a high-volume primary joint unit where cementless TKA has traditionally been used for the majority of patients. METHODS This was a retrospective review of 500 consecutive TKAs performed in patients aged less than 55 years between March 1994 and April 2017. The primary outcome measures for the study were survivorship and all-cause revisions. Secondary outcome measures included nonrevision procedures, clinical, functional, and radiological outcomes. RESULTS An all-cause survival rate of 98.4% and an aseptic survival rate of 99.2% at a median time of 10.7 years (interquartile range 7.3-14.9, range 0.2-27.7) were found. Four patents were revised for infection, 2 for stiffness, 1 for aseptic loosening of the tibial component, and 1 for a patella that was resurfaced for anterior knee pain. Thirty four patients (6.8%) had a nonrevision procedure with manipulation under anesthetic accounting for 27. On a multivariate analysis, preoperative range of motion and female gender were negatively associated with postoperative range of motion (P < .001 and P = .003, respectively). Sixty seven patients (17.3%) had radioluscent lines and on a multivariate analysis, there were no significant predictors of radiolucent lines. CONCLUSION Cementless TKA in the young patient can achieve excellent clinical and functional outcomes. At a median of 10.7 years, aseptic revision rates are exceptionally low at 0.8% for the entire cohort.
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Affiliation(s)
- Gerard A Sheridan
- Primary Joint Unit, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
| | - Roslyn S Cassidy
- Primary Joint Unit, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
| | - Christopher McKee
- Primary Joint Unit, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
| | - Ioan Hughes
- Primary Joint Unit, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
| | - Janet C Hill
- Primary Joint Unit, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
| | - David E Beverland
- Primary Joint Unit, Musgrave Park Hospital, Belfast, Northern Ireland, United Kingdom
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Gelber PE, Ramírez-Bermejo E. Salvage Procedures: Last Chance Before Arthroplasty. OPER TECHN SPORT MED 2022. [DOI: 10.1016/j.otsm.2022.150937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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8
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Hinterwimmer F, Lazic I, Langer S, Suren C, Charitou F, Hirschmann MT, Matziolis G, Seidl F, Pohlig F, Rueckert D, Burgkart R, von Eisenhart-Rothe R. Prediction of complications and surgery duration in primary TKA with high accuracy using machine learning with arthroplasty-specific data. Knee Surg Sports Traumatol Arthrosc 2022; 31:1323-1333. [PMID: 35394135 PMCID: PMC10050062 DOI: 10.1007/s00167-022-06957-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/18/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The number of primary total knee arthroplasties (TKA) is expected to rise constantly. For patients and healthcare providers, the early identification of risk factors therefore becomes increasingly fundamental in the context of precision medicine. Others have already investigated the detection of risk factors by conducting literature reviews and applying conventional statistical methods. Since the prediction of events has been moderately accurate, a more comprehensive approach is needed. Machine learning (ML) algorithms have had ample success in many disciplines. However, these methods have not yet had a significant impact in orthopaedic research. The selection of a data source as well as the inclusion of relevant parameters is of utmost importance in this context. In this study, a standardized approach for ML in TKA to predict complications during surgery and an irregular surgery duration using data from two German arthroplasty-specific registries was evaluated. METHODS The dataset is based on two initiatives of the German Society for Orthopaedics and Orthopaedic Surgery. A problem statement and initial parameters were defined. After screening, cleaning and preparation of these datasets, 864 cases of primary TKA (2016-2019) were gathered. The XGBoost algorithm was chosen and applied with a hyperparameter search, a cross validation and a loss weighting to cope with class imbalance. For final evaluation, several metrics (accuracy, sensitivity, specificity, AUC) were calculated. RESULTS An accuracy of 92.0%, sensitivity of 34.8%, specificity of 95.8%, and AUC of 78.0% were achieved for predicting complications in primary TKA and 93.4%, 74.0%, 96.3%, and 91.6% for predicting irregular surgery duration, respectively. While traditional statistics (correlation coefficient) could not find any relevant correlation between any two parameters, the feature importance revealed several non-linear outcomes. CONCLUSION In this study, a feasible ML model to predict outcomes of primary TKA with very promising results was built. Complex correlations between parameters were detected, which could not be recognized by conventional statistical analysis. Arthroplasty-specific data were identified as relevant by the ML model and should be included in future clinical applications. Furthermore, an interdisciplinary interpretation as well as evaluation of the results by a data scientist and an orthopaedic surgeon are of paramount importance. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Florian Hinterwimmer
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany. .,Institute for AI and Informatics in Medicine, Technical University of Munich, Munich, Germany.
| | - Igor Lazic
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Severin Langer
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christian Suren
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Fiona Charitou
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael T Hirschmann
- Department of Orthopaedic Surgery and Traumatology-Liestal, Kantonsspital Baselland, Bruderholz, Laufen, Switzerland.,Endoprosthetics Committee of the German Knee Society (DKG), Munich, Germany
| | - Georg Matziolis
- Orthopaedic Department Campus Eisenberg, University Hospital Jena, Eisenberg, Germany.,Endoprosthetics Committee of the German Knee Society (DKG), Munich, Germany
| | - Fritz Seidl
- Department of Trauma Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Florian Pohlig
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Daniel Rueckert
- Institute for AI and Informatics in Medicine, Technical University of Munich, Munich, Germany
| | - Rainer Burgkart
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedics and Sports Orthopaedics, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany.,Endoprosthetics Committee of the German Knee Society (DKG), Munich, Germany
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Kfuri M, Crist BD, Stannard JP. Preoperative Planning and Preservation of the Knee with Complex Osteotomies. MISSOURI MEDICINE 2022; 119:144-151. [PMID: 36036038 PMCID: PMC9339400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The knee is a complex structure composed of bone, cartilage, menisci, ligaments and muscles, which all work synergistically to optimize congruence, stability, and function. Osteotomies are procedures addressing an abnormal joint alignment, shifting the mechanical load from a diseased joint compartment to a healthier one. Preoperative planning is an important art of identifying the source of abnormal load distribution to the joint, enabling the surgeon to simulate a deformity correction ahead of the surgical procedure.
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Affiliation(s)
- Mauricio Kfuri
- James P. Stannard and Carolyn A. Stannard Distinguished Professor in Orthopaedic Surgery, Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine, Columbia, Missouri
| | - Brett D Crist
- Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine, Columbia, Missouri
| | - James P Stannard
- Department of Orthopaedic Surgery, University of Missouri - Columbia School of Medicine, Columbia, Missouri
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Keeney JA. CORR Insights: Are There Distinct Statistical Groupings of Mental Health Factors and Pathophysiology Severity Among People with Hip and Knee Osteoarthritis Presenting for Specialty Care? Clin Orthop Relat Res 2022; 480:310-312. [PMID: 34939953 PMCID: PMC8747594 DOI: 10.1097/corr.0000000000002095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023]
Affiliation(s)
- James A Keeney
- Associate Professor, University of Missouri, Columbia, MO, USA
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11
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High usage of medial unicompartmental knee arthroplasty negatively influences total knee arthroplasty revision rate. Knee Surg Sports Traumatol Arthrosc 2022; 30:3199-3207. [PMID: 34191043 PMCID: PMC9418080 DOI: 10.1007/s00167-021-06650-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 06/21/2021] [Indexed: 11/07/2022]
Abstract
PURPOSE Surgeons with higher medial unicompartmental knee arthroplasty (UKA) usage have lower UKA revision rates. However, an increase in UKA usage may cause a decrease of total knee arthroplasty (TKA) usage. The purpose of this study was to investigate the influence of UKA usage on revision rates and patient-reported outcomes (PROMs) of UKA, TKA, and combined UKA + TKA results. METHODS Using the New Zealand Registry Database, surgeons were divided into six groups based on their medial UKA usage: < 1%, 1-5%, 5-10%, 10-20%, 20-30% and > 30%. A comparison of UKA, TKA and UKA + TKA revision rates and PROMs using the Oxford Knee Score (OKS) was performed. RESULTS A total of 91,895 knee arthroplasties were identified, of which 8,271 were UKA (9.0%). Surgeons with higher UKA usage had lower UKA revision rates, but higher TKA revision rates. The lowest TKA and combined UKA + TKA revision rates were observed for surgeons performing 1-5% UKA, compared to the highest TKA and UKA + TKA revision rates which were seen for surgeons using > 30% UKA (p < 0.001 TKA; p < 0.001 UKA + TKA). No clinically important differences in UKA + TKA OKS scores were seen between UKA usage groups at 6 months, 5 years, or 10 years. CONCLUSION Surgeons with higher medial UKA usage have lower UKA revision rates; however, this comes at the cost of a higher combined UKA + TKA revision rate that is proportionate to the UKA usage. There was no difference in TKA + UKA OKS scores between UKA usage groups. A small increase in TKA revision rate was observed for high-volume UKA users (> 30%), when compared to other UKA usage clusters. A significant decrease in UKA revision rate observed in high-volume UKA surgeons offsets the slight increase in TKA revision rate, suggesting that UKA should be performed by specialist UKA surgeons. LEVEL OF EVIDENCE III, Retrospective therapeutic study.
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Suroto H, De Vega B, Deapsari F, Prajasari T, Wibowo PA, Samijo SK. Reverse total shoulder arthroplasty (RTSA) versus open reduction and internal fixation (ORIF) for displaced three-part or four-part proximal humeral fractures: a systematic review and meta-analysis. EFORT Open Rev 2021; 6:941-955. [PMID: 34760293 PMCID: PMC8559569 DOI: 10.1302/2058-5241.6.210049] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Despite rapid medical technology development, various challenges exist in three- and four-part proximal humeral fracture (PHF) management. This condition has led to a notably increased use of the reverse total shoulder arthroplasty (RTSA); however, open reduction and internal fixation (ORIF) is still the most widely performed procedure. Thus, these two modalities are crucial and require further discussion. We aim to compare the outcomes of three- or four-part PHF surgeries using ORIF and RTSA based on direct/head-to-head comparative studies.We conducted a systematic review and meta-analysis based on the Cochrane handbook and PRISMA guidelines. We searched MEDLINE (PubMed), Embase (Ovid), and CENTRAL (Cochrane Library) from inception to October 2020. Our protocol was registered at PROSPERO (registration number CRD42020214681). We assessed the individual study risk of bias using ROB 2 and ROBINS-I tools, then appraised our evidence using the GRADE approach.Six head-to-head comparative studies were included, comprising one RCT and five retrospective case-control studies. We found that RTSA significantly improved forward flexion but was comparable to ORIF in abduction (p = 0.03 and p = 0.47, respectively) and more inferior in external rotation (p < 0.0001). Moreover, RTSA improved the overall Constant-Murley score, but the difference was not significant (p = 0.22). Interestingly, RTSA increased complications (by 42%) but reduced the revision surgery rates (by 63%) compared to ORIF (p = 0.04 and p = 0.02, respectively).RTSA is recommended to treat patients aged 65 years or older with a three- or four-part PHF. Compared to ORIF, RTSA resulted in better forward flexion and Constant-Murley score, equal abduction, less external rotation, increased complications but fewer revision surgeries. Cite this article: EFORT Open Rev 2021;6:941-955. DOI: 10.1302/2058-5241.6.210049.
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Affiliation(s)
- Heri Suroto
- Department of Orthopaedics & Traumatology, Dr. Soetomo General Hospital / Universitas Airlangga, Surabaya, Indonesia
- These authors contributed equally to this work
| | - Brigita De Vega
- Institute of Orthopaedics and Musculoskeletal Science, University College London, London, UK
- Cell & Tissue Bank-Regenerative Medicine Centre, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
- These authors contributed equally to this work
| | - Fani Deapsari
- Cell & Tissue Bank-Regenerative Medicine Centre, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Tabita Prajasari
- Department of Orthopaedics & Traumatology, Dr. Soetomo General Hospital / Universitas Airlangga, Surabaya, Indonesia
| | - Pramono Ari Wibowo
- Department of Orthopaedics & Traumatology, Dr. Soetomo General Hospital / Universitas Airlangga, Surabaya, Indonesia
| | - Steven K. Samijo
- Department of Orthopaedics and Traumatology Zuyderland Medisch Centrum, Heerlen, the Netherlands
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Jiao J, Tang H, Zhang S, Qu X, Yue B. The relationship between mental health/physical activity and pain/dysfunction in working-age patients with knee osteoarthritis being considered for total knee arthroplasty: a retrospective study. ARTHROPLASTY 2021; 3:22. [PMID: 35236496 PMCID: PMC8796639 DOI: 10.1186/s42836-021-00077-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/10/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing total knee arthroplasty (TKA) surgeries are being performed on working-age patients with prominent manifestations of pain and dysfunction. But few studies have explored the risk factors for pain and dysfunction in working-age patients with knee osteoarthritis (KOA) being considered for TKA. Therefore, this study sought to explore the relationship between mental health/physical activity and pain/dysfunction in working-age patients with KOA being considered for TKA. METHODS This study was a secondary analysis of data derived from a public database, the Work participation In Patients with Osteoarthritis cohort study, which included 152 working-age patients (65 men and 87 women) with KOA planning for TKA. We analyzed preoperative data comprising age, educational level, body mass index (BMI), mental factors (Patient Health Questionnaire-9 [PHQ-9] and the 36-Item Short Form Survey Instrument [SF-36 mental health]), physical activity level, and clinical outcomes (the Western Ontario and McMaster Universities Osteoarthritis Index and SF-36 sub-item score). Multivariate regression analysis was performed to determine risk factors for pain and dysfunction in working-age patients with KOA being considered for TKA. RESULTS Women had lower pain, worse function, and higher PHQ-9 scores than men (p < 0.001). The depression scores were significantly linearly related to pain and function scores in women after adjusting for age, BMI, educational level, and physical activity (P < 0.05), whereas this relation was not observed in men. After adjusting for age, BMI, educational level, and mental factors, exercise time was found to be positively correlated with pain scores in women (P < 0.05). CONCLUSIONS Depression scores and exercise time were significantly correlated with pain and dysfunction in working-age women with KOA being considered for TKA.
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Affiliation(s)
- Juyang Jiao
- Department of Bone and Joint Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145, Shandong Road, Shanghai, 200011, China
| | - Haozheng Tang
- Department of Bone and Joint Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145, Shandong Road, Shanghai, 200011, China
| | - Shutao Zhang
- Department of Bone and Joint Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145, Shandong Road, Shanghai, 200011, China
| | - Xinhua Qu
- Department of Bone and Joint Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145, Shandong Road, Shanghai, 200011, China.
| | - Bing Yue
- Department of Bone and Joint Surgery, Department of Orthopaedics, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 145, Shandong Road, Shanghai, 200011, China.
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High Rate of Re-Revision in Patients Less Than 55 Years of Age Undergoing Aseptic Revision Total Knee Arthroplasty. J Arthroplasty 2021; 36:2348-2352. [PMID: 33390338 DOI: 10.1016/j.arth.2020.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/14/2020] [Accepted: 12/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There are limited data on the outcomes of revision total knee arthroplasty in young patients. We sought to characterize the re-revision-free survival and risk factors for re-revision in patients less than 55 years who underwent aseptic revision TKA. METHODS We retrospectively reviewed 197 revision TKAs at a mean follow-up of 5 years. Mean age was 49 years; mean body mass index was 31 kg/m2. Twenty-seven (14%) patients had at least 1 prior revision TKA. The most common indications for revision included instability (29%), arthrofibrosis (26%), and aseptic loosening (24%). Constraint included the following: 59 posterior-stabilized (30%), 123 varus-valgus constrained (62%), and 15 hinged (8%). Components revised included the following: 93 femur/tibia (47%), 68 polyethylene-only (35%), 19 femur-only (10%), and 17 other (9%). Survivorship free from re-revision was calculated via the Kaplan-Meier method and a multivariate Cox proportional regression was utilized to identify risk factors for re-revision. RESULTS Survivorship free from any re-revision at 5 years was 80%. In the multivariate analysis, patients with a prior revision (hazard ratio [HR] = 2.78, P = .02), an isolated polyethylene exchange (HR = 3.0, P = .004), and a hinged prosthesis (HR = 3.47, P = .05) were significant risk factors for lower revision-free survival. Forty-two patients (21%) underwent re-revision, most commonly for periprosthetic joint infection (7%), instability (6%), and aseptic loosening (5%). Re-revision occurred in 18/68 (26%) patients undergoing an isolated polyethylene exchange. CONCLUSION Patients less than 55 years undergoing revision TKA have a modest 5-year revision-free survival of 80%. Patients with prior revision TKAs (HR = 2.78), hinge type prostheses (HR = 3.47), and polyethylene-only revisions (HR = 3.0) had higher revision rates.
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Gould D, Dowsey MM, Spelman T, Jo O, Kabir W, Trieu J, Bailey J, Bunzli S, Choong P. Patient-Related Risk Factors for Unplanned 30-Day Hospital Readmission Following Primary and Revision Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:E134. [PMID: 33401763 PMCID: PMC7795505 DOI: 10.3390/jcm10010134] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 01/10/2023] Open
Abstract
Total knee arthroplasty (TKA) is a highly effective procedure for advanced osteoarthritis of the knee. Thirty-day hospital readmission is an adverse outcome related to complications, which can be mitigated by identifying associated risk factors. We aimed to identify patient-related characteristics associated with unplanned 30-day readmission following TKA, and to determine the effect size of the association between these risk factors and unplanned 30-day readmission. We searched MEDLINE and EMBASE from inception to 8 September 2020 for English language articles. Reference lists of included articles were searched for additional literature. Patients of interest were TKA recipients (primary and revision) compared for 30-day readmission to any institution, due to any cause, based on patient risk factors; case series were excluded. Two reviewers independently extracted data and carried out critical appraisal. In-hospital complications during the index admission were the strongest risk factors for 30-day readmission in both primary and revision TKA patients, suggesting discharge planning to include closer post-discharge monitoring to prevent avoidable readmission may be warranted. Further research could determine whether closer monitoring post-discharge would prevent unplanned but avoidable readmissions. Increased comorbidity burden correlated with increased risk, as did specific comorbidities. Body mass index was not strongly correlated with readmission risk. Demographic risk factors included low socioeconomic status, but the impact of age on readmission risk was less clear. These risk factors can also be included in predictive models for 30-day readmission in TKA patients to identify high-risk patients as part of risk reduction programs.
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Affiliation(s)
- Daniel Gould
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Michelle M Dowsey
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
- Department of Othopaedics, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia
| | - Tim Spelman
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Olivia Jo
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Wassif Kabir
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Jason Trieu
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - James Bailey
- School of Computing and Information Systems, University of Melbourne, 3052 Melbourne, Australia;
| | - Samantha Bunzli
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
| | - Peter Choong
- Department of Surgery, University of Melbourne, St. Vincent’s Hospital Melbourne, 3065 Melbourne, Australia; (M.M.D.); (T.S.); (O.J.); (W.K.); (J.T.); (S.B.); (P.C.)
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Schwartz AM, Farley KX, Guild GN, Bradbury TL. Projections and Epidemiology of Revision Hip and Knee Arthroplasty in the United States to 2030. J Arthroplasty 2020; 35:S79-S85. [PMID: 32151524 PMCID: PMC7239745 DOI: 10.1016/j.arth.2020.02.030] [Citation(s) in RCA: 338] [Impact Index Per Article: 84.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 01/22/2020] [Accepted: 02/12/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND As the incidence of primary total joint arthroplasty rises in the United States, it is important to investigate how this will impact rates of revision arthroplasty. The purpose of this study was to analyze the incidence and future projections of revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) to 2030. Anticipating surgical volume will aid surgeons in designing protocols to efficiently and effectively perform rTHA/rTKA. METHODS The national inpatient sample was queried from 2002 to 2014 for all rTHA/rTKA. Using previously validated measures, Poisson and linear regression analyses were performed to project annual incidence of rTHA/rTKA to 2030, with subgroup analyses on modes of failure and age. RESULTS In 2014, there were 50,220 rTHAs and 72,100 rTKAs. From 2014 to 2030, rTHA incidence is projected to increase by between 43% and 70%, whereas rTKA incidence is projected to increase by between 78% and 182%. The 55-64 and 65-74 age groups increased in revision incidence during the study period, whereas 75-84 age group decreased in incidence. For rTKA, infection and aseptic loosening are the 2 most common modes of failure, whereas periprosthetic fracture and infection are most common for rTHA. CONCLUSION The incidence of rTHA/rTKA is projected to increase, particularly in young patients and for infection. Given the known risk factor profiles and advanced costs associated with revision arthroplasty, our projections should encourage institutions to generate revision-specific protocols to promote safe pathways for cost-effective care that is commensurate with current value-based health care trends. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Andrew M. Schwartz
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA,Department of Orthopaedic Surgery, Emory University Orthopaedics & Spine Hospital, Tucker, GA,Reprint requests: Andrew M. Schwartz, MD, Department of Orthopaedic Surgery, Emory University School of Medicine, 59 Executive Park Drive, SE, Atlanta, GA 30329
| | - Kevin X. Farley
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA
| | - George N. Guild
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA,Department of Orthopaedic Surgery, Emory University Orthopaedics & Spine Hospital, Tucker, GA
| | - Thomas L. Bradbury
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA,Department of Orthopaedic Surgery, Emory University Orthopaedics & Spine Hospital, Tucker, GA
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Gender Differences in Contribution of Smoking, Low Physical Activity, and High BMI to Increased Risk of Early Reoperation After TKA. J Arthroplasty 2020; 35:1545-1557. [PMID: 32067896 DOI: 10.1016/j.arth.2020.01.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/20/2020] [Accepted: 01/20/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The reliable preoperative identification of patients at a high risk of early reoperations (<2 years after primary surgery) after total knee arthroplasty (TKA) could lead to adjustments of the surgical procedure and counseling, thus lowering the percentage of revision surgeries. METHODS The unselected cohort consisted of 1885 patients (695 men and 1190 women) who underwent TKA implantation between September 2010 and April 2017 at a single tertiary orthopedic center. Multivariate patient similarity networks were applied to identify patient groups at a high risk of early reoperations based on 25 preoperative parameters. RESULTS Early reoperations (109 cases, 5.8%) were less frequent in women (4.4%; median time to reoperation, 2.0 months) than in men (8.2%; 7.5 months), reaching the highest incidence in younger men (10.9%; <66 years). Of the tested preoperative parameters, the risk of reoperation in men was more likely associated with smoking or obesity (body mass index [BMI] > 30). In women, low physical activity and high BMI were the most likely risk factors for early reoperations. Other factors did not affect the risk of early reoperations, including the primary diagnosis, comorbidities, and surgeon-implanting TKA. CONCLUSION This study demonstrates the effect of smoking, physical activity, and BMI on the risk of early reoperation after TKA, with the different contribution in men/women. Identification of patient subgroups with a higher risk of early revision after TKA is needed for clinical implementation of precision medicine in orthopedics.
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Cemented total-knee arthroplasty in rheumatoid arthritis patients aged under 60 years. Chin Med J (Engl) 2019; 132:2760-2761. [PMID: 31725444 PMCID: PMC6940091 DOI: 10.1097/cm9.0000000000000502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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