Increase in Operative Time Is Associated With Postoperative Complications in Revision Total Knee Arthroplasty

Suction-Powered Intramedullary Bone Debridement Technology Compared to Conventional Curettage in Infected Revision Total Knee Arthroplasty

Background

Revision total knee arthroplasty (TKA) in the United States is an increasingly common procedure, often performed in the setting of prosthetic joint infection. Debridement of the intramedullary canals is traditionally performed with surgical curettes and is technically difficult and time-intensive. A suction-powered bone harvester (SPBH) is designed to improve the quality of debridement in a closed-capture system. This study assesses conventional curettage (CC) versus SPBH in debridement mass and time from intramedullary spaces. We hypothesize that SPBH will increase debridement yield more efficiently than conventional curettes.

Methods

Adult patients undergoing revision TKA were enrolled to participate in the study and were divided into 2 groups. Patients in group 1 received tibial debridement with CC followed by SPBH and femoral canals with SPBH alone. Patients in group 2 received femoral debridement with CC followed by SPBH and tibial canals with SPBH alone.

Results

Data were collected from 30 revision TKA cases in the setting of prosthetic joint infection. In total, 14 femora and 16 tibiae were initially debrided with SPBH, while the opposites were debrided with CC. On average, the intramedullary debridement with SPBH yielded 23.1 g compared to 13.2 g with CC (P = .0017). The intramedullary canal required 1 minute 28 seconds for debridement with SPBH compared to 2 minutes for debridement with CC (P = .0347). Culture data from samples obtained from SPBH were noninferior to CC.

Conclusions

SPBH is an effective tool for debridement of intramedullary canal during revision TKA. SPBH led to a significant increase of debrided mass in significantly less time than CC. There was no difference in positive culture yield between the 2 debridement techniques. This debridement technique merits consideration to reduce bioburden in revision TKA.

Fellowship-Trained Surgeons Experience a Learning Curve Performing Revision Total Joint Arthroplasty

BACKGROUND

Revision total hip arthroplasty (rTHA) and revision total knee arthroplasty (rTKA) require considerable surgical proficiency, but are frequently delegated to the least experienced surgeons. This study examined the influence of surgeon experience on revision outcomes.

METHODS

Prospective data on confirmed aseptic rTHAs (n = 122) and rTKAs (n = 195) performed by 4 fellowship-trained surgeons in the same practice were retrospectively analyzed. Surgeons were grouped based on years in practice (inexperienced [IE] first 2 years, early experience [EE] 4 to 6 years, and senior experience [SE] 15 to 17 years). Procedure duration, estimated blood loss (EBL), and reoperation rates were compared, controlling for potential covariates.

RESULTS

Procedure durations varied based on surgeon experience for 3 of 4 rTHA diagnoses (P ≤ 0.001). Relative to the SE surgeon, procedure duration was 80.0 (95% confidence interval 61.7 to 98.4, P < 0.001) minutes longer for IE surgeons and 30.9 (95% confidence interval 17.5 to 44.3, P < 0.001) minutes longer for the EE surgeon. Procedure durations also varied based on surgeon experience for 3 of 4 rTKA diagnoses (P < 0.001), with the longest durations for IE surgeons. Procedure durations varied based on the interaction of surgeon experience, patient age, and body mass index. The EBL did not differ in rTHA based on surgeon experience (P = 0.978), but did differ for rTKA (P = 0.004). There were 25% of rTHAs performed by IE surgeons compared to 15.5% for the EE surgeon and 3.6% for the SE surgeon that underwent reoperation within a year of the index procedure (P = 0.064), with significantly more reoperations for the same indication among IE and EE surgeons (P = 0.046).

CONCLUSIONS

Complex procedures completed by less experienced surgeons may result in longer procedures, higher EBL, and more early reoperations. Study findings implicate a learning curve for revision arthroplasty that continues for several years, warranting consideration of existing patient allocation and referral patterns.

Short-term adverse event rates and risk factors following total elbow arthroplasty for fracture and arthropathy: a matched analysis of nationally representative data

BACKGROUND

Total elbow arthroplasty (TEA) is a mainstay treatment for elbow arthropathy and elbow fracture that can relieve pain and restore functional motion. The purpose of this study was to determine the role of surgical indication in the incidence of short-term adverse events and risk factors influencing complications in TEA to treat arthropathy compared to TEA for fracture. Matched cohorts were created to better isolate the impact of the surgical indication.

METHODS

The study identified patients within the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database that underwent TEA to treat arthropathy or fracture from 2010 to 2020. Matched cohorts were created to analyze the incidence of 30 day adverse events and risk factors for complications.

RESULTS

The study included 599 patients for analysis. The overall incidence of any adverse event was 9.7%. In matched cohorts of 218 patients, the fracture group experienced a higher incidence of overall adverse events (13.8% vs. 6.0% in the arthropathy group, p = 0.009) and postoperative transfusions (9.6% vs. 1.8% in the arthropathy group, p < 0.001). Logistic regression revealed an increased risk of any adverse event in the combined matched cohort with longer operative times (OR = 1.007, CI: 1.002-1.012, p = 0.006) and those undergoing fracture treatment (OR = 2.447, CI: 1.047-5.717, p = 0.039). Outpatient status was associated with a lower risk of adverse events in the combined matched cohort (OR = 0.207, CI: 0.058-0.739, p = 0.015).

CONCLUSIONS

Even when controlling for comorbidities, patients undergoing TEA for fracture have a greater likelihood of short-term complications, particularly requiring a blood transfusion. Treatment of a fracture and increased operative time were risk factors for all patients, while outpatient status was protective.

LEVEL OF EVIDENCE

III.

Clinical Outcomes of Offset Stem Couplers with or without Cone Augmentation in Revision Total Knee Arthroplasty

Intramedullary stems are often required in patients undergoing revision total knee arthroplasty (rTKA) to achieve stable fixation. Significant bone loss may require the addition of a metal cone to maximize fixation and osteointegration. The purpose of this study was to investigate clinical outcomes in rTKA using different fixation techniques. We conducted a single-institution retrospective review of all patients who received a tibial and femoral stem during rTKA between August 2011 and July 2021. Patients were separated into three cohorts based on fixation construct: press-fit stem with an offset coupler (OS), fully cemented straight (CS) stem, and press-fit straight (PFS) stem. A subanalysis of patients who received tibial cone augmentation was also conducted. A total of 358 patients who underwent rTKA were included in this study, of which 102 (28.5%) had a minimum 2-year follow-up and 25 (7.0%) had a minimum 5-year follow-up. In the primary analysis, 194 patients were included in the OS cohort, 72 in the CS cohort, and 92 in the PFS cohort. When stem type alone was considered, there was no significant difference in rerevision rate (p = 0.431) between cohorts. Subanalysis of patients who received augmentation with a tibial cone demonstrated that OS implants led to significantly higher rates of rerevision compared with the other two stem types (OS: 18.2% vs. CS: 2.1% vs. PFS: 11.1%; p = 0.037). The findings of the present analysis demonstrate that CS and cones in rTKA may provide more reliable long-term outcomes compared with press-fit stems with OS. LEVEL III EVIDENCE:  Retrospective Cohort Study.

Impact of time to revision total knee arthroplasty on outcomes following aseptic failure

INTRODUCTION

Prior studies have demonstrated an association between time to revision total knee arthroplasty (rTKA) and indication; however, the impact of early versus late revision on post-operative outcomes has not been reported.

MATERIALS AND METHODS

A retrospective, observational study examined patients who underwent unilateral, aseptic rTKA at an academic orthopedic hospital between 6/2011 and 4/2020 with > 1-year of follow-up. Patients were early revisions if they were revised within 2 years of primary TKA (pTKA) or late revisions if revised after greater than 2 years. Patient demographics, surgical factors, and post-operative outcomes were compared.

RESULTS

470 rTKA were included (199 early, 271 late). Early rTKA patients were younger by 2.5 years (p = 0.002). The predominant indications for early rTKA were instability (28.6%) and arthrofibrosis/stiffness (26.6%), and the predominant indications for late rTKA were aseptic loosening (45.8%) and instability (26.2%; p < 0.001). Late rTKA had longer operative times (119.20 ± 51.94 vs. 103.93 ± 44.66 min; p < 0.001). There were no differences in rTKA type, disposition, hospital length of stay, all-cause 90-day emergency department visits and readmissions, reoperations, and number of re-revisions.

CONCLUSIONS

Aseptic rTKA performed before 2 years had different indications but demonstrated similar outcomes to those performed later. Early revisions had shorter surgical times, which could be attributed to differences in rTKA indication.

LEVEL OF EVIDENCE

III, retrospective observational analysis.

Intraoperative technology increases operating room times in primary total knee arthroplasty

INTRODUCTION

Optimization of patient outcomes and identification of factors to improve the surgical workflow are increasingly important. Operating room time is one modifiable factor that leads to greater hospital efficiency as well as improved outcomes such as shorter length of stay and fewer infections and readmissions. The aim of this study was to identify factors associated with operative time disparities in total knee arthroplasty (TKA).

METHODS

A retrospective review of 7659 consecutive primary TKA cases was conducted. Patient demographic data, discrete operating room (OR) times, use of technology (i.e. robotic-assisted surgery, computer navigation), surgeon experience and the level of training of the first assistant were collected. Multivariate regression analysis was used to determine the effect of hospital characteristics on operative times. Operative times of five minutes or greater were considered to be clinically significant.

RESULTS

While the use of technology (182.64 ± 39.85 vs 158.70 ± 37.45 min; B = 26.09; p < 0.0001) and greater surgeon experience (162.14 ± 39.87 vs 158.69 ± 33.18 min, B = 3.15, p = 0.002) were found to increase OR times, level of training of the first assist (161.65 vs 156.4 min; Β = - 0.264; p = 0.487) did not. Of the discrete OR times examined, incision time and total time under anesthesia were negatively impacted by the use of technology.

CONCLUSION

Use of technology was the only study variable found to significantly increase OR times. With increased operative times and limited evidence that technology improves long-term patient outcomes, surgeons should carefully consider the benefits and cost of technology in TKA.

The effect of BMI and other factors on post-operative length of stay: A multivariable regression analysis of 860 patients undergoing total knee arthroplasty

BACKGROUND

There is a trend towards minimising length of stay (LOS) after total knee arthroplasty (TKA), as greater LOS is associated with poorer outcomes and higher costs. Patient factors known to influence LOS post-TKA include age and ASA grade. Evidence regarding the effect of body mass index (BMI) in particular is conflicting, with some studies finding that increased BMI predicts increased LOS, while others have found no relationship. Few previous studies, which have mostly been conducted outside the UK, have examined the effect of living alone or socioeconomic deprivation, which may be confounders.

METHODS

We conducted a retrospective cohort study of 1031 consecutive primary TKAs performed between 1 April 2021 and 31 December 2021 in a single high-volume arthroplasty centre. A multivariable negative binomial regression model was performed for the 860 patients with complete data, using pre-operative (BMI, age, gender, ASA grade, smoking, ethnicity, socioeconomic deprivation, living arrangement, EQ5D quality of life score, and indication for surgery) and peri-operative variables (surgeon, surgical approach, tourniquet use, a.m./p.m operation, operation side, duration, and day of the week).

RESULTS

Mean LOS was 2.6 days. BMI and socioeconomic deprivation had no effect on LOS (P > 0.05). Increased LOS was associated with living alone, lower EQ5D, age and ASA grade (all P < 0.001), p.m. operation (P < 0.01), female gender and duration of surgery (P < 0.05).

CONCLUSION

BMI and socioeconomic status were not correlated with LOS after TKA. Living alone, which has not been previously reported and lower pre-operative EQ5D status were significant risk factors, which merit consideration in pre-operative planning and counselling.

Are Infection Rates Increased After Sterilization of the External Fixator During Staged Internal Fixation of High-Energy Tibial Plateau Fractures?

OBJECTIVES

To compare infection rates after second-stage definitive surgery for high-energy tibial plateau fractures between groups of patients who had the external fixator prepped into the surgical field and those who did not.

DESIGN

Retrospective cohort study.

SETTING

Two academic Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Two hundred forty-four patients met inclusion and exclusion criteria between the 2 institutions.

INTERVENTION

Prepping of the external fixator into the surgical field during second-stage definitive open reduction and internal fixation. 162 patients were in the prepped group, and 82 patients were in the nonprepped group.

MAIN OUTCOME MEASUREMENTS

The primary outcome was the rate of deep infection after definitive fixation. Secondary outcome was operative time.

RESULTS

There were no significant differences in infection rates between prepped (11.7%) and nonprepped (18.3%) groups ( P = 0.162). Patients in the prepped groups had significantly decreased operative time (168.2 minutes vs. 221.9 minutes, P &lt; 0.001) even after controlling for confounders in regression analysis.

CONCLUSIONS

There is no increased risk of infection associated with prepping and maintenance of the external fixator during definitive internal fixation for high-energy tibial plateau fractures. These data suggest that this practice may lead to shorter operative times as well.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.