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BACKGROUND: The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has continued to generate notable disruption in elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of this study was to determine whether there is any difference in patient characteristics, revenue, and clinical outcomes in patients undergoing THA and TKA after the start of the pandemic. METHODS: We reviewed a consecutive series of 26,493 patients undergoing primary and revision THA and TKA by 48 surgeons in a single arthroplasty practice. We compared demographics, comorbidities, outcomes, and surgeon revenue from THA and TKA procedures from March 2020 to February 2021 with a prepandemic group undergoing a procedure from March 2019 to February 2020. RESULTS: There was a 20% decline in the volume of all cases in the pandemic group ( 11,688 versus 14,664 , P < 0.001). The postpandemic cohort had shorter length of stay (1.58 versus 1.70 days, P = 0.007), had higher rates of home discharge (98% versus 91%, P < 0.001), and were more likely to have their procedure done at an outpatient facility (21% versus 7%, P < 0.001). Even among patients older than 65 years, more pandemic patients underwent a procedure as an outpatient (19% versus 7%, P < 0.001), with no difference in complications or readmissions. Total surgeon charges and payments declined by 17.6% and 16.3%, respectively, during the pandemic ( P = 0.010). CONCLUSION: Although the COVID-19 pandemic resulted in a notable reduction in surgical volume and revenue loss for our practice, we found a marked shift of arthroplasty patients to outpatient facilities with increased rates of home discharge without compromising patient safety.

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BACKGROUND: Multimodal analgesia has become the standard of care for pain management following total knee arthroplasty (TKA). Cannabidiol (CBD) is increasingly utilized in the postoperative period. The purpose of this study was to analyze the analgesic benefits of topical CBD following primary TKA. METHODS: In this randomized double-blinded placebo-controlled trial, 80 patients undergoing primary unilateral TKA applied topical CBD (CBD; n = 19), essential oil (EO; n = 21), CBD and essential oil (CBD + EO; n = 21), or placebo (PLA; n = 19) thrice daily around the knee for two weeks postoperatively. This supplemented a standardized multimodal analgesic protocol. Outcomes included visual analog scale (VAS) pain and numeric rating scale (NRS) sleep scores (collected on postoperative day [POD] 0, 1, 2, 7, 14, 42), and cumulative postoperative opioid use (42 days). RESULTS: Demographic characteristics were similar among the four cohorts. Preoperative VAS and NRS scores were similar among groups. The CBD cohort had a higher mean VAS pain score on POD 2 compared to the EO cohort (CBD: 69.9 ± 19.3 versus. EO: 51.0 ± 18.2; P = .013). No statistically significant differences existed for VAS scores at other times, and no statistically significant differences were observed for postoperative NRS sleep scores or postoperative opioid use at any time point. CONCLUSION: Utilization of topical CBD in supplement to multimodal analgesia did not reduce pain or opioid consumption, or improve sleep scores following TKA. These results suggest that the local effects of topical CBD are not beneficial for providing additional pain relief after TKA.

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BACKGROUND: Simultaneous bilateral total knee arthroplasty (sim-BTKA) is reported to be safe in a select group of patients. Patients with symptomatic bilateral knee arthritis who are not candidates for sim-BTKA require staged surgery (stag-BTKA). This study aimed to compare the safety and complications associated with sim-BTKA with stag-BTKA performed at 2 time intervals. METHODS: This retrospective study of prospectively collected data includes bilateral TKA cases performed between 2001 and 2019. A cohort of sim-BTKA (n = 2728) was compared to a cohort of stag-BTKA (n = 1658). The staged group was subdivided according to the interval between surgeries: ≤90 days (early) and ≥91 days (later). Multivariate logistic regression analyses were used to adjust for confounding variables. RESULTS: In-hospital complication rates were lower in both arms of the stag-BTKA groups vs the sim-BTKA. The sim-BTKA group had higher odds ratio of anemia, electrolyte disturbances, pulmonary embolism, and respiratory, urinary, gastrointestinal, and neurological complications. Lower rates of all-cause revision were found in stag-BTKA vs sim-BTKA groups. There was a trend toward revision due to deep infection when increasing the interim before the second stag-BTKA procedure. No differences in complication rates after the second surgery were detected between the early and later stag-BTKA. CONCLUSION: This study demonstrates that sim-BTKA is associated with more complications and revisions when compared to stag-BTKA. Performing the second-stage TKA at 90 days or less after the first TKA is not associated with increased risk of complications. Performing sim-BTKA, simply for convenience, is not warranted and should be reserved for a select group of patient matching specific criteria.

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INTRODUCTION: Mortality after total joint arthroplasty (TJA) has been thoroughly explored. Short and long-term mortality appear to be correlated with patient comorbidities. Red Cell Distribution Width (RDW) is a commonly performed test that reflects the variation in red blood cell size. This study investigated the utility of RDW, when combined with comorbidity indices, in predicting mortality after TJA. METHODS: Using a single institutional database, 30,437 primary TJA were identified. Patient demographics (age, gender, body mass index (BMI), pre-operative hemoglobin, RDW, and Charlson Comorbidity Index(CCI)) were queried. The primary outcome was 1-year mortality after TJA. Anemia was defined as hemoglobin <12g/dL for women and <13 g/dL for men. The normal range for RDW is 11.5-14.5%. A preliminary analysis assessed the bivariate association between demographics, preoperative anemia, RDW, CCI, and all-cause mortality within 1-year after TJA. A multivariate regression model was conducted to determine independent predictors of 1-year mortality. Finally, ROC curves were used to compare AUC of RDW, CCI and the combination of both in predicting 1-year mortality. RESULTS: The mean RDW was 13.6% ± 1.2. Eighteen percent of patients had pre-operative anemia. The mean CCI was 0.4 ± 0.9. RDW, anemia, CCI, and age were significantly associated with a higher incidence of 1-year mortality. RDW, CCI, age, and male sex were found to be independent risk factors for 1-year mortality. RDW (AUC = 0.68) was a better predictor of mortality compared to CCI (AUC = 0.66). The combination of RDW and CCI (AUC = 0.76) predicted 1-year mortality more accurately than CCI or RDW alone. CONCLUSION: RDW appears to be a useful parameter that, when combined with CCI, can predict the risk for 1-year mortality after TJA.

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INTRODUCTION: The rationale for discarding the skin knife blade and replacing it with another blade for deeper dissection is to prevent bacteria that may be present on the skin from being carried into the deeper layers of the wound. This practice is very controversial because numerous, yet limited, studies exist that support and refute the findings. The purpose of this study was to directly compare the rate of contamination of a skin knife blade with a control blade. METHODS: We took the surface samples using Replicate Organism Detection and Counting plates of 344 knife blades immediately after making skin incision during the following four types of orthopaedic cases: total hip arthroplasty, total knee arthroplasty, lumbar spine surgery, and cervical spine surgery. At the same time, we sampled 344 control blades. The comparison of positives skin versus control, overall and within each subgroup was done using a bivariate two-sample z-test for the equality of proportions. RESULTS: Overall, 35 (5.1%) of the 688 specimens had a positive result. No difference was noted in the rate of positive cultures for the 344 skin blades 4.9% and the 344 control blades 5.2%. No differences were observed in the rate of positive specimens for skin blades (7.4%, 3.4%, 7.7%, and 3.9%) and control blades (2.5%, 4.1%, 7.7%, and 9.2%) for total hip arthroplasty, total knee arthroplasty, C spine, and L spine, respectively. No differences were observed regarding skin prep, room number, case order, room turnover time, or in-room to incision time. Staphylococus species was the predominant bacteria identified. CONCLUSION: We found no evidence to support the theoretical advantage of changing the knife blade after making skin incision to avoid contamination. Contamination rates were the same for both the skin and control blades overall and for all subgroup analysis.

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Bone marrow lesions of the knee in patients with osteoarthritis (OA-BML) are an important clinical entity that may explain progressive pain, decreased quality of life, and impaired function. MRI of OA-BMLs demonstrates a region of subchondral bone with hyperintense marrow signal on T2-weighted images. Histopathology retrieval studies have demonstrated that these lesions correlate with microdamage of the trabecular bone, and subsequently, this leads to a vicious cycle of subchondral bone attrition, attempts at repair, pain, and progressive deformity. These lesions have also been linked to accelerated loss of adjacent articular cartilage and increases in the severity of knee pain, prompting patients to seek musculoskeletal care and treatment. Multiple studies have also correlated the presence of an OA-BML with an increased probability of seeking knee arthroplasty. Knowledge of these lesions is important in the context that knee OA is both a cartilage-based and bone-based disease. Further study of OA-BMLs may provide opportunities for early intervention and OA disease-modifying treatments.

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BACKGROUND: Total knee arthroplasty (TKA) for the majority of patients with severe knee osteoarthritis provides relief of symptoms and improved function. However, there remains a subset of dissatisfied patients despite an unremarkable workup. A corticosteroid injection (CSI) is a commonly used nonsurgical treatment for painful knee osteoarthritis but its efficacy in a replaced knee remains unknown. METHODS: A retrospective chart review identified primary TKA patients who subsequently received a CSI into a replaced knee from 2015 to 2016 by a single surgeon. Patients receiving a CSI underwent clinical examination, laboratory analysis to rule out infection, and radiographic evaluation before CSI. Patient variables were recorded and a patient satisfaction survey assessed the efficacy of the injection. The survey response rate was 70.1%. RESULTS: Of the 129 responders, 82.9% remembered the injection. The average time from index arthroplasty to injection was median 5.3 months (interquartile range, 2.1-23.4) and 30.8% of patients received more than 1 injection (range, 1-5). Overall, 76.6% reported decreased pain, 57.9% reported increased motion, and 65.4% reported long-term decreased swelling. Improvement lasted greater than 1 month for 56.1% of patients, and overall 84.1% reported improvement (slight to great) in the knee following CSI. No patient developed a periprosthetic joint infection (PJI) within 1 year of injection. CONCLUSION: This study suggests that certain patients following TKA may benefit from a CSI. However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out conditions unlikely to improve long term from a CSI.

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PURPOSE: Accurate alignment and balanced flexion and extension gaps are critical elements in achieving a successful outcome following total knee arthroplasty (TKA). The ability to make accurate and precise bone cuts is essential in the creation of balanced gaps. We sought to determine if one type of modern-day standard surgical instrument using an intramedullary rod and posterior referencing produces accurate and precise distal and posterior femoral bone resections. MATERIALS AND METHODS: Seventy-five consecutive patients undergoing TKA were divided into three groups, with 25 patients in each group receiving one of three implant designs: 25 Stryker Triathlon® CR (Stryker, Mahwah, NJ), 25 Zimmer NexGen® Flex CR (Zimmer, Warsaw, IN), and 25 StelKast Proven Gen-FlexTM CR (StelKast, Pittsburgh, PA). Flexion-extension gap matching was determined using only the medial flexion and extension gaps. Accuracy was determined by comparing actual resection thickness to desired resection thickness. "Optimal" accuracy was considered to be within 1.0mm of desired, and "near-optimal" accuracy was considered to be within 2.0mm of the desired resection thickness. Precision was determined by the variability of resection thicknesses within each system. RESULTS: Data demonstrated a lack of accuracy and precision across all three tested systems, with each system resulting in certain unique tendencies. Only one out of 75 cases resulted in optimal resection accuracy with all three cuts (Zimmer). When lowering the threshold to include both optimal and near-optimal (within 2 mm of error) with all three cuts, only one third of Stryker and Zimmer cases and two thirds of StelKast cases achieved this threshold, representing 44% of cases (33/75). CONCLUSIONS: Improvements in instrumentation to increase accuracy and precision may be warranted. Errors in fixation may be due to the instrumentation itself, and altering instrumentation to include less modularity, provide more stable fixation, and more reliably seal the implant on the femur may be of benefit.

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