RESUMEN
BACKGROUND: The clinical examination for laxity has been considered a mainstay in evaluation of the painful knee arthroplasty, especially for the diagnosis of instability. More than 10 mm of anterior-posterior (AP) translation in flexion has been described as important in the diagnosis of flexion instability. The inter-observer reliability of varus/valgus and AP laxity testing has not been tested. METHODS: Ten subjects with prior to total knee arthroplasty (TKA) were examined by 4 fellowship-trained orthopedic knee arthroplasty surgeons. Each surgeon evaluated each subject in random order and was blinded to the results of the other surgeons. Each surgeon performed an anterior drawer test at 30 and 90 degrees of flexion and graded the instability as 0-5 mm, 5-10 mm or >10 mm. Varus-valgus testing was also graded. Motion capture was used during the examination to determine the joint position and estimate joint reaction force during the examination. RESULTS: Inter-rater reliability (IRR) was poor at 30 and 90 degrees for both the subjective rater score and the measured AP laxity in flexion (k = 018-0.22). Varus-valgus testing similarly had poor reliability. Force applied by the rater also had poor IRR. CONCLUSION: Clinical testing of knee laxity after TKA has poor reliability between surgeons using motion analysis. It is unclear if this is from differences in examiner technique or from differences in pain or quadriceps function of the subjects. Instability after TKA should not be diagnosed strictly by clinical testing and should involve a complete clinical assessment of the patient.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Inestabilidad de la Articulación , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/métodos , Fenómenos Biomecánicos , Humanos , Inestabilidad de la Articulación/cirugía , Articulación de la Rodilla/cirugía , Dolor/cirugía , Rango del Movimiento Articular , Reproducibilidad de los ResultadosRESUMEN
BACKGROUND: There is a paucity of literature to guide non-operative treatment for patients with problems after total knee arthroplasty (TKA). We sought to quantify how quadriceps and hamstring strength could improve with focused physical therapy (PT) and whether improving leg strength may prevent revision surgery for patients with flexion instability (FI) after TKA. METHODS: This retrospective study included patients diagnosed with FI by one of the 4 fellowship-trained arthroplasty surgeons at a single academic institution. Patients with FI were referred for strength measurements and a focused PT program. In total, 166 patients completed isokinetic testing to quantify their relative quadriceps and hamstring power, torque, and work measures compared to their contralateral leg. Fifty-five (33.5%) patients subsequently completed post-PT isokinetic testing. Statistical analysis was conducted to evaluate strength deficits in the knee with FI. RESULTS: Patients with FI were found to be 20.5%-38.4% weaker in all strength domains compared to the contralateral leg (P < .001). Patients who completed PT and pre-isokinetic and post-isokinetic testing demonstrated statistically significant gains in all extension metrics by a net range of 24.7%-34.2% (P = .011-.029) and their flexion strength metrics improved by 32.5%-40.2% (P = .002-.005). About 81.9% of patients in this subgroup did not undergo revision TKA. Those subjects who went on to revision did not statistically improve in any strength domain (P = .063-.121). CONCLUSION: Patients with FI after TKA have significantly weaker quadriceps and hamstrings in the operative compared to contralateral leg. Patients who did not undergo revision knee arthroplasty and completed a formal PT program improved quadriceps and hamstring strength by 30%. LEVEL OF EVIDENCE: IV (Case series).
Asunto(s)
Músculos Isquiosurales , Humanos , Articulación de la Rodilla/cirugía , Fuerza Muscular , Músculo Cuádriceps , Rango del Movimiento Articular , Estudios RetrospectivosRESUMEN
BACKGROUND: Prosthetic joint infection (PJI) is associated with significant morbidity, mortality, and costs. We developed a fast-track PJI care system using an infectious disease physician to work directly with the TJA service and coordinate in the treatment of PJI patients. We hypothesized that streamlined care of patients with hip and knee PJI decreases the length of the acute hospital stay without increasing the risk of complication or incorrect antibiotic selection. METHODS: A single-center retrospective chart review was performed for all patients treated operatively for PJI. A cohort of 78 fast-track patients was compared to 68 control patients treated before the implementation of the program. Hospital length of stay (LOS) and cases of antibiotic mismatch were primary outcomes. Secondary outcomes, including 90-day readmissions, reoperations, mortality, rate of reimplantation, and 12-month reimplant survival, were compared. Cox regressions were analyzed to assess the effects on LOS of patient demographics and the type of surgery performed. RESULTS: Average hospital LOS from infection surgery to discharge was significantly lower in the fast-track cohort (3.8 vs 5.7 days; P = .012). There were no episodes of antibiotic mismatch in the fast-track group vs 1 recorded episode in the control group. No significant differences were noted comparing 90-day complications, reimplantation rate, or 12-month reimplant survival rates. CONCLUSION: Through the utilization of an orthopedic-specific infectious disease physician, a fast-track PJI protocol can significantly shorten hospital LOS while remaining safe. Streamlining care pathways may help decrease the overall healthcare costs associated with treating PJI.
Asunto(s)
Artritis Infecciosa , Artroplastia de Reemplazo de Cadera , Artroplastia de Reemplazo de Rodilla , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Rodilla/efectos adversos , Hospitales , Humanos , Tiempo de Internación , Estudios RetrospectivosRESUMEN
BACKGROUND: Multiple papers have purported the superiority of spinal anesthesia used in total joint arthroplasty (TJA). However, there is a paucity of data available for modern general anesthesia (GA) regimens used at high-volume joint replacement centers. METHODS: We retrospectively reviewed a series of 1527 consecutive primary TJAs (644 total hip arthroplasties and 883 total knee arthroplasties) performed over a 3-year span at a single institution that uses a contemporary GA protocol and report on the length of stay, early recovery rates, perioperative complications, and readmissions. RESULTS: From the elective TJAs performed using a modern GA protocol, 96.3% (n = 1471) of patients discharged on postoperative day 1, and 97.2% (n = 1482) of subjects were able to participate with physical therapy on the day of surgery. Only 6 patients (0.4%) required an intensive care unit stay postoperatively. The 90-day readmission rate over this time was 2.4% (n = 36), while the reoperation rate was 1.3% (n = 20). DISCUSSION: Neuraxial anesthesia for TJA is commonly preferred in high-volume institutions utilizing contemporary enhanced recovery pathways. Our data support the notion that the utilization of modern GA techniques that limit narcotics and certain inhalants can be successfully used in short-stay primary total joint arthroplasty. LEVEL OF EVIDENCE: IV- Case series.
Asunto(s)
Anestesia General/efectos adversos , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Anciano , Anestesia General/métodos , Arkansas/epidemiología , Artroplastia de Reemplazo de Cadera/efectos adversos , Artroplastia de Reemplazo de Cadera/rehabilitación , Artroplastia de Reemplazo de Rodilla/efectos adversos , Artroplastia de Reemplazo de Rodilla/rehabilitación , Procedimientos Quirúrgicos Electivos , Recuperación Mejorada Después de la Cirugía , Femenino , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Complicaciones Posoperatorias/etiología , Reoperación/estadística & datos numéricos , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: Early discharge after joint arthroplasty requires additional resources to manage patients safely after surgery. Patient concerns must be addressed during nonbusiness hours to keep patients out of the emergency department and avoid readmissions. The goal of our study was to determine how type of system is utilized in a busy early discharge joint replacement practice. METHODS: In our total joint program, we have utilized a Google phone number to give patients access to a member of the surgical team after business hours and on weekends. The duration, chief complaint, and resolution of from the phone calls were collected prospectively for 3 months (July 3, 2017-October 3, 2017). RESULTS: Sixty-eight calls were received from 55 patients during the 3-month study period. Three hundred twenty-five cases were performed. The average duration of a call was 3.9 minutes. The average length of time from surgery to call was 17.5 days (range 0-442 days). Suboptimal health literacy was associated with increased calls within the first week after surgery (odds ratio = 4.1, 95% confidence interval = 1.2-14.5, P = .022). A chief complaint of pain was associated with primary versus revision surgery. (odds ratio = 3.23, 95% confidence interval = 1.08-9.86). DISCUSSION: An "after-hours" telephone contact service with a member of the surgical team may help avoid unnecessary emergency department visits. About one phone call was received per day, with an average duration of 3.9 minutes per call. These additional resources are necessary to maintain patient safety and satisfaction in early discharge joint replacement.
Asunto(s)
Atención Posterior/estadística & datos numéricos , Artroplastia de Reemplazo/efectos adversos , Ortopedia/estadística & datos numéricos , Arkansas/epidemiología , Artroplastia de Reemplazo de Cadera , Alfabetización en Salud , Humanos , Oportunidad Relativa , Alta del Paciente , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , TeléfonoRESUMEN
Flexion instability after total knee arthroplasty (TKA) is caused by an increased flexion gap compared with extension gap. Patients present with recurrent effusions, subjective instability (especially going downstairs), quadriceps weakness, and diffuse periretinacular pain. Manual testing for laxity in flexion is commonly done to confirm a diagnosis, although testing positions and laxity grades are inconsistent. Nonsurgical treatment includes quadriceps strengthening and bracing treatment. The mainstays to surgical management of femoral instability involve increasing the posterior condylar offset, decreasing the tibial slope, raising the joint line in combination with a thicker polyethylene insert, and ensuring appropriate rotation of implants. Patient outcomes after revision TKA for flexion instability show the least amount of improvement when compared with revisions for other TKA failure etiologies. Future work is needed to unify reproducible diagnostic criteria. Advancements in biomechanical analysis with motion detection, isokinetic quadriceps strength testing, and computational modeling are needed to advance the collective understanding of this underappreciated failure mechanism.
Asunto(s)
Artroplastia de Reemplazo de Rodilla , Inestabilidad de la Articulación/etiología , Inestabilidad de la Articulación/terapia , Prótesis de la Rodilla/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Fenómenos Biomecánicos , Evaluación de la Discapacidad , Humanos , Dimensión del Dolor , Examen Físico , Radiografía , ReoperaciónRESUMEN
BACKGROUND: Total joint arthroplasty has historically been very successful for most patients, yet some still incur a complication. In an era of value-based care, certain efforts need to be taken to optimize patients' risk profile before surgery to decrease the chances of readmission or surgical complication. METHODS: We reviewed 10 key medical conditions and lifestyle factors that surgeons should improve before pursuing total joint arthroplasty and provide a summary of the available literature to guide certain optimization thresholds. RESULTS: With careful attention to and the creation of a preoperative checklist, surgeons can identify key domains, including morbid obesity, malnutrition, diabetes, smoking, opioid use, poor dentition, cardiovascular disease, preoperative anemia, staphylococcus colonization, and psychological disorders and intervene based on an individual's areas of deficiencies. CONCLUSION: By following stringent protocols and rescheduling surgery until optimization has occurred, we can work to provide patients the best chance for a successful outcome with an elective hip or knee arthroplasty.