Sense of coherence as a predictor for patients' quality of recovery after total hip or knee arthroplasty - A descriptive cohort study

BACKGROUND

Patients' postoperative quality of recovery (QOR) is an important outcome measurement and predicting and preventing impaired quality of recovery is essential. In this study, we aimed to investigate if patients Sense of Coherence (SOC) could be a potential predictor and screening instrument for impaired quality of recovery. We hypothesized that patients' SOC is positively related to their QOR.

MATERIAL AND METHODS

The study was performed as a descriptive single-center prospective cohort study. Data was collected using digital questionnaires. Patients undergoing total hip (THA) or knee arthroplasty (TKA) received the SOC13 questionnaire prior to their surgery to establish their SOC and a questionnaire on postoperative day 2 and 7, respectively, establishing their QOR. Multiple linear regression was used to fit a model for the QOR score using SOC, age, sex, and type of surgery as potential explanatory variables.

RESULTS

206 patients were included in the study analysis. The results showed a highly significant positive correlation between patients' SOC and their postoperative QOR on both postoperative day 2 and 7 (p < 0.01). Patients with a lower SOC score also presented a significantly lower QOR score, meaning they experienced impaired QOR compared to patients with a higher SOC score.

CONCLUSIONS

The results indicate that a weak SOC (low SOC score) can be considered a clinically important indicator for risk of impaired QOR (low QOR score) after THA and TKA. The SOC13 questionnaire may be a potential screening instrument identifying patients in risk of impaired postoperative QOR based on a low SOC score.

Treatment of post-traumatic complete bony ankylosed elbow using total arthroplasty and hernia patch - A case report

INTRODUCTION AND IMPORTANCE

The elbow is one of the most mobile joints, and its movement is very important. Bony ankylosed elbow is an uncommon condition leading to complete loss of activity of elbow, and then lead to severe disability and limitation in activities of daily living.

CASE PRESENTATION

A 63-year-old woman sustained comminuted fracture of left distal humerus. She underwent open reduction and internal fixation by plates. After the plates were removed in 2016，stiffness developed.The elbow was stable but fixed at 90°，there was no vascular injury or deficit in sensory and motor function of the ulnar nerve. She hopes to eliminate pain and restore normal mobility compatible with ADL.

CLINICAL DISCUSSION

Complete bony ankylosis of the elbow joint may be caused by trauma, rheumatic disease, burns, congenital stiffness and other conditions. Even with the compensation of shoulder and wrist, it will still have a great impact on upper limb function. Whether to treat mainly depends on whether the patient has the require to improve the functionality and return to daily activities. Treatment methods are very limited, including interposition arthroplasty and TEA. Defect of soft tissue appeared was seen in our case, Hernia Patch was innovatively applied to reconstruct the defect of soft tissue and maintain continuity of elbow extension mechanism.

CONCLUSION

Patients with post-traumatic elbow joint ankylosis were suffered from severe bony abnormalities, but also soft tissue contracture or defects due to multiple operations and trauma. We present a case of complete bony ankylosed elbow treated with total elbow arthroplasty and Hernia Patch.

Robotic-assisted mechanically aligned total knee arthroplasty does not lead to better clinical and radiological outcomes when compared to conventional TKA: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Robotic-assisted total knee arthroplasty (R-TKA) has emerged as an alternative to improve the results of the conventional manual TKA (C-TKA). The aim of this study was to analyse the high-level studies comparing R-TKA and C-TKA in terms of clinical outcomes, radiological results, perioperative parameters, and complications.

METHODS

The literature search was conducted on three databases (PubMed, Cochrane, and Web of Science) on 1 February 2023 according to the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Inclusion criteria were: randomized controlled trials (RCTs), written in English language, published in the last 15 years, focusing on the comparison of C-TKA and R-TKA results. The quality of each article was assessed using the Cochrane risk-of-bias tool for randomized trials version 2 (RoB 2). The statistical analysis was carried out using random effects (DerSimonian & Laird) for weighted mean difference (MD) of the continuous variables and Peto method for odds ratios of the dichotomous variables.

RESULTS

Among the 2905 articles retrieved, 14 RCTs on 12 series of patients treated with mechanically aligned implants were included. A total of 2255 patients (25.1% males and 74.9% females; mean age 62.9 ± 3.0; mean BMI 28.1 ± 1.3) were analysed. The results of this systematic review and meta-analysis showed that R-TKA did not provide overall superior results compared to C-TKA in mechanically aligned implants in terms of clinical and radiological outcomes. R-TKA showed longer operative time (MD = 15.3 min, p = 0.004) and similar complication rates compared to C-TKA. A statistically significant difference in favour of R-TKA was found in the posterior-stabilized subgroup in terms of radiological outcomes (hip-knee-ankle angle MD = 1.7, p < 0.001) compared to C-TKA, although without resulting in appreciable difference of clinical outcomes.

CONCLUSION

R-TKA did not provide overall superior results compared to C-TKA in terms of clinical and radiological outcomes, showing longer operative time and similar complication rates.

LEVEL OF EVIDENCE

Level I.

[Fracture sequelae type 2 of the proximal humerus-clinical results after arthroplasty]

Locked dislocations of the glenohumeral joint are rare but often painful and are associated with limited range of motion in the shoulder. In patients of advanced age, arthroplasty is increasingly indicated as a surgical treatment option. Preoperatively, the direction of dislocation, the presence and extent of a glenoid defect, and the soft tissue situation (rotator cuff status, joint capsule) should be analyzed in a differentiated manner. Based on the above factors, we recommend the subclassification of type 2 according to Boileau: posterior locked dislocation (2a), anterior locked dislocation without glenoid defect (2b), and anterior locked dislocation with glenoid defect (2c). In the case of dorsally locked dislocation, a good clinical result can be achieved by using an anatomical endoprosthesis. For ventrally locked dislocations, we recommend using an inverse total endoprosthesis with, if necessary, bony glenoid reconstruction and transfer of the pectoralis major muscle.Level of evidence: IV.

A systematic review of total arthroplasty and arthrodesis for end-stage hallux rigidus: A biomechanical perspective

BACKGROUND

Both arthrodesis and total arthroplasty are acceptable surgical options for end stage hallux rigidus without significant angular deformity. Total arthroplasty preserves first metatarsophalangeal joint (MTPJ) motion, which may help restore a more physiological gait pattern.

RESEARCH QUESTION

Is there a difference in the findings of gait studies after 1st MTPJ total arthroplasty or arthrodesis for end-stage hallux rigidus?

METHODS

PRISMA guidelines were followed to conduct a systematic review of literature for studies reporting gait analysis after the above procedures. Predetermined criteria were used to select papers and evaluated the findings of kinematic (spatial-temporal and dynamic motion), kinetic and foot pressure (pedobarographic) studies.

RESULTS

12 titles were short-listed for synthesis. There was 1 randomized controlled trial comparing the two procedures. Among the remaining cohort studies, 5 reported on total arthroplasty and 6 on arthrodesis of the 1st MTPJ. Due to significant heterogeneity, a narrative synthesis was undertaken. No studies in the arthroplasty group reported spatial-temporal or kinetic parameters. Only 2 papers, 1 in each group, recorded motion within the foot. One of them showed preserved dynamic motion at the 1st MTPJ after total arthroplasty. Pedobarographic studies had discordant findings in studies within both groups regarding restoration of weight bearing through the medial forefoot and the pulp of the great toe during gait.

CONCLUSION

Currently available studies are heterogenous and report inconsistent findings, which do not convincingly answer our research question. Prospective comparative studies with a large sample size, using standardized methodology in accredited laboratories with detailed reporting of kinetic, kinematic and pedobarographic components of gait analysis are required in order to draw concrete conclusions.

Bone remodeling, around an anatomical hip stem: a one year prospective study using DEXA

INTRODUCTION

The loss of bone mass, as a consequence of bone remodelling, in the proximal third of the femur, is a factor that contributes to the failure of hip prostheses in the medium to long term. This periprosthetic remodelling occurs mainly during the first 12 months after the operation. The aim is to evaluate the behaviour at one year of a new anatomical stem, the ANATO® stem (2015-Stryker®), which is a redesign of its predecessor (ABG-ii®-Stryker stem) by means of bone densitometry.

METHOD

Prospective, controlled study in which the changes in bone mineral density (BMD) observed around the seven areas of Gruen in a group of 61 patients affected by primary coxarthrosis, in whom an ANATO® stem was implanted, are analysed densitometrically. The healthy hip was taken as the control group. The existence of differences in the remodelling pattern according to sex, age and body mass index (BMI) was compared. The follow-up was during the first year after the intervention.

RESULTS

After one year of follow-up, decreases of bone mineral density in zone seven of -5.9% were observed, being this decrease statistically significant. No differences were found in the remodelling pattern according to age, sex and body mass index.

CONCLUSION

The ANATO® stem allows an efficient transmission of loads from the stem to the proximal femur. Only in zone seven significant bone atrophy is observed. Differences in age, BMI and sex do not seem to influence the bone remodelling around this new stem.

Bone Remodeling of Two Anatomic Stems: Densitometric Study of the Redesign of the ABG-II Stem

Background

Periprosthetic bone remodeling, which is a phenomenon observed in all femoral stems, has a multifactorial origin as it depends on factors related to the patient, the surgical technique, and the design of the implant. To determine the pattern of remodeling produced by 2 models of anatomic cementless implants, we quantified the changes in bone mineral density (BMD) in the 7 areas of Gruen observed at different moments after surgery during the first postoperative year.

Methods

A prospective, comparative, controlled, 1-year follow-up densitometric study was carried out in 2 groups of patients suffering from primary unilateral hip osteoarthritis. In the first group, with 68 patients, an ABG-II stem was implanted. In the second, with 66 patients, the ANATO stem was used. The contralateral, healthy hip was taken as a control.

Results

Both groups showed a decrease in BMD at 3 months in all the areas, which recovered at the end of the study, except in zone 7: there was a 17.7% decrease in the ABG-II group and a 5.9% decrease in the ANATO group. In zones 2 and 6, where more loads are transmitted, conservation of BMD is observed in response to Wolff's law. The differences in the pattern of remodeling between groups were maintained despite the age, gender, and BMI of the patients or the size of the implants.

Conclusion

The ANATO stem achieved a more efficient transmission of loads at the metaphyseal level, which promotes bone preservation at the proximal femur, than the ABG-II stem.

Review article: Patient characteristics that act as risk factors for intraoperative complications in hip, knee, and shoulder arthroplasties

The number of annual THA's, TKA's, and TSA's is set to increase significantly by the year 2030, making it imperative to understand the risks for negative outcomes in these procedures. While research has studied the patient risk factors for perioperative and postoperative complications, there has been relatively little research for intraoperative complications. After a thorough literature review, the most supported finding was that patients with a BMI >30 had significantly more intraoperative blood loss than those with a BMI <30. All other relationships between patient risk factors and intraoperative complications of interest were inadequately studied.

[Total elbow arthroplasty in an older adult patient, as a therapeutic option for the management of pseudoarthrosis in distal humerus fracture]

INTRODUCTION

Distal humeral fractures in the elderly patient are a therapeutic challenge for orthopaedists, because of ages characteristic physiological conditions and bone changes.

CASE REPORT

We present the case of an 80-year-old woman with osteopenia, who had distal humeral fracture due to a fall from her own height; she was initially treated conservatively, but by the reason of a non-union, we decided to perform a total elbow arthroplasty, achieving a positive functional result in the four years of postoperative follow-up.

DISCUSSION

Nonsurgical management is an option for treat humeral fractures in patients with low functional demands or in poor general condition. If the patient does not present the conditions above, or if nonsurgical management fails, a total elbow arthroplasty must be performed, because this method provides a rapid recovering if compared to an open reduction and osteosynthesis material management.

What are the benefits and risks of total arthroplasty in arthrodesed knees?

INTRODUCTION

The conversion of a previously arthrodesed knee to a total knee arthroplasty is an alternative seldom used. However, arthroplasty would provide greater functionality to the arthrodesed joint. Since it is a technically demanding procedure, not exempt from complications, there is controversy about the role of this intervention.

METHODS

To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified two systematic reviews including 10 studies overall, none of which corresponded to a randomized trial. We concluded the conversion of knee arthrodesis to total knee arthroplasty could increase the functionality, but it is not clear whether it increases the complications or if it has any impact on pain or patient satisfaction because the certainty of the evidence is very low.

Assessment of anatomical and reverse total shoulder arthroplasty with the scapula-weighted Constant-Murley score

AIM OF THE STUDY

To evaluate total (TSA) and reverse total shoulder arthroplasty (RTSA) using the Constant-Murley score (CMS) and the scapula-weighted (SW) CMS, an integrated outcome measure that takes into account the compensatory movements of the scapula.

METHODS

Twenty-five consecutive patients, 12 with TSA and 13 with RTSA, underwent kinematic analysis before and after shoulder replacement. Measurements included flexion (FLEX) and abduction (ABD) for the humerus and Protraction-Retraction (PR-RE), Medio-Lateral rotation (ME-LA), and Posterior-Anterior tilting (P-A) for the scapula. They were recorded at baseline (T0) and at six (T1) and 12 months (T2). Reference data were obtained from 31 control shoulders.

RESULTS

At T1, differences in CMS and SW-CMS were not significant in either group, whereas values at T2 were significantly lower in RTSA patients (p = 0.310 and p = 0.327, respectively). In TSA shoulders, the compensatory scapular movements in FLEX were all reduced from T0 to T2, whereas P-A was increased in ABD. In RTSA patients, the compensatory scapular movements in FLEX showed a general reduction at T1, with an increase in P-A at T2, whereas in ABD, all increased at T1 and decreased at T2 except for P-A, which did not decrease.

DISCUSSION

The SW-CMS showed that the physiological scapulothoracic motion was not restored in TSA and RTSA patients; it may be used as a reference for the gradual progression of deltoid and scapular muscle rehabilitation.

CONCLUSIONS

The worse CMS and SW-CMS scores found in RTSA patients at six months may be due to the biomechanics of the reverse prosthesis and to the weakness of deltoid and periscapular muscles.

Minimal clinically important difference of Liverpool Elbow Score in elbow arthroplasty

Background

The minimal clinically important difference (MCID) that allows the interpretation of small but meaningful changes after intervention has not been reported for the Liverpool Elbow Score (LES). This study aimed to determine the MCID for the LES in patients undergoing total elbow replacement.

Methods

This observational study is based on preoperative and 1-year postoperative clinical outcome of total elbow replacement (Discovery Elbow System) in 71 patients using the LES. A 4-point Likert-like transition scale was used to evaluate patient satisfaction after total elbow replacement. A combination of distribution-based methods (standard deviation [SD] of change in the LES, standard error of mean, smallest detectable change [SDC]) and anchor-based methods (receiver operating curve, difference of mean of change in LES) was used to determine range of MCID values.

Results

The mean change in the LES value was 2.4 (SD, 2.1). The estimated SDC value with upper limit of 90% confidence interval was 1.5. The mean change in LES of “satisfied” and “somewhat satisfied” patient groups was 2.4 (SD, 2.1) and 1.1 (SD, 1.4), respectively, and the difference between both means (MCID based on difference of mean in 2 subgroups) was 1.3. According to receiver operating curve analysis, the value of MCID was 1.6.

Conclusion

The MCID value for the LES was estimated to range between 0.7 and 1.8. The estimated SDC value was 1.5. We propose that the “true” MCID value of the LES would be between 1.6 and 1.8 to ensure that the value is higher than the measurement error of the LES.

Total joint Perioperative Surgical Home: an observational financial review

Background

The numbers of people requiring total arthroplasty is expected to increase substantially over the next two decades. However, increasing costs and new payment models in the USA have created a sustainability gap. Ad hoc interventions have reported marginal cost reduction, but it has become clear that sustainability lies only in complete restructuring of care delivery. The Perioperative Surgical Home (PSH) model, a patient-centered and physician-led multidisciplinary system of coordinated care, was implemented at UC Irvine Health in 2012 for patients undergoing primary elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). This observational study examines the costs associated with this initiative.

Methods

The direct cost of materials and services (excluding professional fees and implants) for a random index sample following the Total Joint-PSH pathway was used to calculate per diem cost. Cost of orthopedic implants was calculated based on audit-verified direct cost data. Operating room and post-anesthesia care unit time-based costs were calculated for each case and analyzed for variation. Benchmark cost data were obtained from literature search. Data are presented as mean ± SD (coefficient of variation) where possible.

Results

Total per diem cost was $10,042 ± 1,305 (13%) for TKA and $9,952 ± 1,294 (13%) for THA. Literature-reported benchmark per diem cost was $17,588 for TKA and $16,267 for THA. Implant cost was $7,482 ± 4,050 (54%) for TKA and $9869 ± 1,549 (16%) for THA. Total hospital cost was $17,894 ± 4,270 (24%) for TKA and $20,281 ± 2,057 (10%) for THA. In-room to incision time cost was $1,263 ± 100 (8%) for TKA and $1,341 ± 145 (11%) for THA. Surgery time cost was $1,558 ± 290 (19%) for TKA and $1,930 ± 374 (19%) for THA. Post-anesthesia care unit time cost was $507 ± 187 (36%) for TKA and $557 ± 302 (54%) for THA.

Conclusions

Direct hospital costs were driven substantially below USA benchmark levels using the Total Joint-PSH pathway. The incremental benefit of each step in the coordinated care pathway is manifested as a lower average length of stay. We identified excessive variation in the cost of implants and post-anesthesia care.