Alex Gu

Adult Reconstruction Hip and Knee Fellowship Program Content and Accessibility

BACKGROUND The objective of the study was to assess the accessibility and content of accredited adult reconstruction hip and knee fellowship program websites. METHODS Using the online database of the American Association of Hip and Knee Surgeons (AAHKS), we compiled a list of accredited adult hip and knee/tumor reconstruction fellowship programs. A full list of adult reconstruction hip and knee fellowship programs was gathered from the AAHKS website. The program website links they provided were evaluated. A Google search was conducted to identify program websites and analyzed for accessibility and content in 3 domains: program overview, applying/recruitment, and education. RESULTS At the time the study was conducted, there were 78 accredited adult reconstruction hip and knee fellowship programs identified through the AAHKS program directory. Three of the 78 programs identified had a functional link on the AAHKS fellowship program directory; however, Google search identified 60 websites. Eighteen programs did not have a website and were not evaluated for content. Data analysis of content in the domains of program details, application process/recruitment, and education revealed that most websites included a program description and director name with contact information. However, they were not as comprehensive in the application process/recruitment and education domains. CONCLUSIONS AAHKS provides a reasonable method of identifying programs. Yet, most programs can readily be identified using a Google search (76.9%). Although most fellowship program websites contained program details, there is still paucity of information for fellowship candidates.

Efficacy of Revision Surgery for the Treatment of Stiffness After Total Knee Arthroplasty: A Systematic Review

BACKGROUND Knee stiffness following total knee arthroplasty (TKA) may cause pain and reduced functionality, contributing to unsatisfactory surgical outcomes. Revision surgery remains a possible treatment for refractory postoperative stiffness. However, the efficacy of the procedure has not been systematically evaluated. METHODS A systematic review of the literature was performed to identify studies that reported on outcomes for patients who underwent revision surgery for postoperative stiffness after TKA. RESULTS Ten studies (including 485 knees) were reviewed. The most common etiologies of stiffness requiring revision TKA were component malposition, malalignment, overstuffing, aseptic loosening, arthrofibrosis, patella baja, and heterotopic ossification. Of 9 studies reviewing range of motion outcomes after revision TKA, 7 studies documented significant improvement and 2 found trends toward improvement. Seven of 8 studies documenting Knee Society knee scores and 7 of 9 studies documenting functional scores found improvement after revision TKA. All studies reporting on pain found improvement at final follow-up after revision TKA. CONCLUSION Revision TKA results in increased range of motion, improved functionality, and reduced pain in most patients who require surgery for stiffness. The present literature is inadequate to predict which patients will achieve adequate outcomes from revision TKA based on the specific etiology of their stiffness, although identification of the etiology may help in surgical planning. Surgeons performing revision TKA should counsel patients on the risks and benefits of undergoing revision surgery, with the understanding that outcomes for well-selected patients are generally favorable.

Prognostic Factors that Predict Failure of Manipulation Under Anesthesia for the Stiff Total Knee Arthroplasty: A Systematic Review

Purpose Prognostic factors associated with Manipulation under anesthesia (MUA) failure remain unknown. Methods A systematic review of the literature was performed to identify studies that reported prognostic factors associated with MUA for postoperative stiffness. Results 7 studies analyzing prognostic factors associated with MUA outcomes were included. Several studies note pre-MUA ROM to be a significant prognostic factor affecting post-MUA ROM at final follow-up. Knees with <70° of flexion pre-MUA had less final flexion arc than those with >70°. Conclusions The strongest prognostic factor for decreased ROM after MUA is severe pre-MUA stiffness.

Surgical Treatment of Cubital Tunnel in Pediatric Athletes

Background Cubital tunnel syndrome is the second most common upper extremity peripheral nerve entrapment syndrome. In particular, cubital tunnel has been documented occasionally in young, throwing athletes. Materials and Methods Billing databases were searched for patients undergoing surgical decompression of the ulnar nerve at the elbow, who were age 18 or younger at the time of surgery. Charts were reviewed and patients were included if they had an isolated mononeuropathy consistent with cubital tunnel syndrome and were symptomatic. Data on age of onset, duration of symptoms, Dellon classification, nerve subluxation, provocative testing results, nerve conductions, and exacerbating activities were abstracted. Patients were contacted for a postsurgical follow-up questionnaire. Results Seven patients were identified. The average age was 16, and duration of symptoms was 7 months. All seven patients had normal electrodiagnostic studies and had failed a course of conservative treatment. All were satisfied with surgery and felt improvement. One stopped playing their sport, and three had mild symptoms with varied activities. Conclusion Although uncommon, pediatric cubital tunnel syndrome does occur. Surgical release improves symptoms and return to activities. Nevertheless, some degree of symptoms often persists. Electrodiagnostic studies may be negative in many patients with an otherwise consistent history and examination. Level of Evidence This is a level IV therapeutic study.

The Impact of Chronic Obstructive Pulmonary Disease on Postoperative Outcomes in Patients Undergoing Revision Total Knee Arthroplasty.

BACKGROUND Total knee arthroplasty (TKA) utilization is increasing in older Americans. The incidence of chronic obstructive pulmonary disease (COPD) has been steadily rising over the past few decades. In particular, COPD is being increasingly more common in patients undergoing revision TKA. The aim of this study is to identify the impact of COPD on postoperative complications for patients undergoing revision TKA. METHODS A retrospective cohort study was conducted using data collected through the American College of Surgeons National Quality Improvement Program Database. All patients who underwent revision TKA between 2007 and 2014 were identified and stratified into groups based on COPD status. The incidence of adverse events after surgery was evaluated with univariate and multivariate analyses where appropriate. RESULTS Patients with COPD were found to develop more postoperative complications, including deep wound infection, organ infection, wound dehiscence, pneumonia, reintubation, renal insufficiency, urinary tract infection, myocardial infarction, sepsis, and death. Patients with COPD were also shown to have to return back to the operating room and have an extended length of hospital stay. COPD was shown to be an independent risk factor for development of wound dehiscence, pneumonia, reintubation, renal insufficiency, and renal failure. Finally, COPD was identified as an independent risk factor for unplanned return to the operating room. CONCLUSION Patients with COPD have greater risk for postoperatively developing wound dehiscence, pneumonia, reintubation, renal insufficiency, and renal failure complications than those without COPD. While risks for independent complications remain relatively low, consideration of COPD status is an important factor to consider when selecting surgical candidates and preoperative risk assessment.

Is Discharge Within a Day of Total Knee Arthroplasty Safe in the Octogenarian Population

BACKGROUND Reduced hospital stay programs for total knee arthroplasty (TKA) are being implemented in order to increase patient satisfaction and reduce healthcare costs. Although elderly patients are often included in these pathways, there have been limited data on whether older patients can safely be discharged within a day after TKA. The purpose of this study is to compare perioperative complications following primary TKA with ≤1 day in the hospital in patients aged ≥80 compared to <80 years old in the National Surgical Quality Improvement Program database. METHODS Patients who underwent primary TKA with hospital length of stay ≤1 day were identified in the 2005-2016 National Surgical Quality Improvement Program database. These patients were separated into 2 age groups: <80 and ≥80 years old. Preoperative and procedural characteristics were compared. Multivariate regressions were used to compare risk for perioperative adverse events and readmission. Independent risk factors for serious adverse events following such TKAs were identified. RESULTS In total, 17,191 (<80 year olds) and 1005 (≥80 year olds) cases were identified. Of these patients, 1750 cases were discharged the same day. Multivariate analysis revealed only higher risk for 30-day readmission and nonhome discharge in ≥80 compared to <80 year olds. Notably, the octogenarians had a significantly higher rate of nonsurgical site-related readmissions. Independent risk factors for serious adverse events include only American Society of Anesthesiologists score ≥3 and not patient age. CONCLUSION These data suggest that, although octogenarians can safely be discharged in ≤1 day, greater postdischarge care may be warranted to reduce the rate of nonsurgical site-related readmissions.

Efficacy of Manipulation Under Anesthesia for Stiffness Following Total Knee Arthroplasty: A Systematic Review

BACKGROUND Knee stiffness following primary total knee arthroplasty can lead to unsatisfactory patient outcomes secondary to persistent pain and loss of function. Manipulation under anesthesia (MUA) remains a viable option for treatment of post-operative stiffness. However, the optimal timing and clinical efficacy of manipulation of anesthesia remains unknown. METHODS A systematic review of the literature was performed to identify studies that reported clinical outcomes for patients who underwent MUA for post-operative stiffness treatment. Repeat MUA procedures were included in the study but were analyzed separately. RESULTS Twenty-two studies (1488 patients) reported on range of motion (ROM) after MUA, and 4 studies (81 patients) reported ROM after repeat MUA. All studies reported pre-MUA motion of less than 90°, while mean ROM at last follow-up exceeded 90° in all studies except 2. For studies reporting ROM improvement following repeat MUA, the mean pre-manipulation ROM was 80° and the mean post-manipulation ROM was 100.6°. CONCLUSION MUA remains an efficacious, minimally invasive treatment option for post-operative stiffness following TKA. MUA provides clinically significant improvement in ROM for most patients, with the best outcomes occurring in patients treated within 12 weeks post-operatively. PROSPERO REGISTRATION NUMBER CRD42016052215.