Ali Oliashirazi

Comparison of Radiographic Alignment of Imageless Computer-Assisted Surgery vs Conventional Instrumentation in Primary Total Knee Arthroplasty

A total of 208 patients were enrolled in a multicenter, prospective randomized, institutional review board-approved study that compared preoperative surgical plan to postoperative 2-dimensional radiographic alignment measured by a blinded reviewer for primary total knee arthroplasty (TKA) implanted using computer-assisted surgery (CAS) compared with conventional TKA instrumentation. The results demonstrated a statistically significant improvement in the coronal tibial component alignment (P < .03) and failed to demonstrate a statistically significant improvement in the mechanical axis, femoral coronal/sagittal, and tibial sagittal alignment. Knee Society Score knee and function scores and 6-minute walk test were equivalent between the 2 treatment groups at all postoperative intervals. There was a statistically significant increase in the skin-skin time (P < .0001) and the time until first bone cut (P < .0001) for the CAS knees compared with those implanted with conventional instrumentation. The use of CAS in this randomized clinical trial conducted at high-volume centers did not offer a clinically meaningful improvement in postoperative alignment, clinical, functional, or safety outcomes compared with conventional TKA.

Periprosthetic patellar fractures

Patellar fracture after total knee arthroplasty is a rare yet challenging complication. Patellar fracture can occur as a result of trauma or it may be atraumatic. A multitude of factors can lead to periprosthetic patellar fracture including patient related factors, surgical technique related factors, and implant specific factors. Understanding the etiologic factors leading to atraumatic patellar fractures could result in minimizing complications. We present the results of peri- prosthetic patellar fractures in 12 patients. All type I non- displaced fractures (7 cases) were treated nonoperatively. Surgical treatment was selected for the remaining 5 cases which included resection arthroplasty combined with open reduction and internal fixation of the fracture (3 knees), partial patellectomy (1 knee), and total patellectomy (1 knee). The outcome was excellent in 1 knee, good in 8 knees, and fair in the remaining 3 knees at the latest follow-up. There were 2 reoperations; 1 for disruption of the extensor mechanism and 1 for refracture. One patient developed a superficial wound infection. We reviewed the available literature regarding the etiology, surgical strategies, and outcomes for periprosthetic patellar fracture.Level of Evidence: Therapeutic studies, level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Patient‐Controlled Fentanyl Iontophoretic Transdermal System Improved Postoperative Mobility Compared to Intravenous Patient‐Controlled Analgesia Morphine: A Pooled Analysis of Randomized, Controlled Trials

Postoperative pain management protocols that use patient‐controlled analgesia (PCA) can hinder mobility due to attached machinery and tubing. Immobility in the postoperative setting can increase complications, length of stay (LOS), and costs. Early and enhanced mobilization can reduce the cost of care while improving patient outcomes. A needle‐free, compact, patient‐activated, and portable fentanyl iontophoretic transdermal system (fentanyl ITS, IONSYS; The Medicines Company, Parsippany NJ) has been shown to provide comparable efficacy and tolerability to intravenous (IV) PCA morphine that promotes improved mobility.

Reliability, Concurrent Validity, and Minimal Detectable Change for iPhone Goniometer App in Assessing Knee Range of Motion

Abstract Much of the published works assessing the reliability of smartphone goniometer apps (SG) have poor generalizability since the reliability was assessed in healthy subjects. No research has established the values for standard error of measurement (SEM) or minimal detectable change (MDC) which have greater clinical utility to contextualize the range of motion (ROM) assessed using the SG. This research examined the test‐retest reproducibility, concurrent validity, SEM, and MDC values for the iPhone goniometer app (i‐Goni; June Software Inc., v.1.1, San Francisco, CA) in assessing knee ROM in patients with knee osteoarthritis or those after total knee replacement. A total of 60 participants underwent data collection which included the assessment of active knee ROM using the i‐Goni and the universal goniometer (UG; EZ Read Jamar Goniometer, Patterson Medical, Warrenville, IL), knee muscle strength, and assessment of pain and lower extremity disability using quadruple numeric pain rating scale (Q‐NPRS) and lower extremity functional scale (LEFS), respectively. Intraclass correlation coefficients (ICCs) were calculated to assess the reproducibility of the knee ROM assessed using the i‐Goni and UG. Bland and Altman technique examined the agreement between these knee ROM. The SEM and MDC values were calculated for i‐Goni assessed knee ROM to characterize the error in a single score and the index of true change, respectively. Pearson correlation coefficient examined concurrent relationships between the i‐Goni and other measures. The ICC values for the knee flexion/extension ROM were superior for i‐Goni (0.97/0.94) compared with the UG (0.95/0.87). The SEM values were smaller for i‐Goni assessed knee flexion/extension (2.72/1.18 degrees) compared with UG assessed knee flexion/extension (3.41/1.62 degrees). Similarly, the MDC values were smaller for both these ROM for the i‐Goni (6.3 and 2.72 degrees) suggesting smaller change required to infer true change in knee ROM. The i‐Goni assessed knee ROM showed expected concurrent relationships with UG, knee muscle strength, Q‐NPRS, and the LEFS. In conclusion, the i‐Goni demonstrated superior reproducibility with smaller measurement error compared with UG in assessing knee ROM in the recruited cohort. Future research can expand the inquiry for assessing the reliability of the i‐Goni to other joints.

Characterizing the recovery trajectories of knee range of motion for one year after total knee replacement

ABSTRACT Design: Retrospective analysis of routinely collected clinical data. Objective: This study modeled the recovery in knee flexion and extension range of motion (ROM) over 1 year after total knee replacement (TKR). Background: Recovery after TKR has been characterized for self-reported pain and functional status. Literature describing target knee ROM at different follow-up periods after TKR is scarce. Methods: Data were extracted for patients who had undergone TKR at a tertiary care hospital at 2, 8, 12, 26, and 52 weeks after TKR. A linear mixed-effects growth model was constructed that investigated the following covariates age, sex, pre-TKR range, body mass index, duration of symptoms, and their interaction with weeks post TKR. Results: Of the 559 patients included (age 64.8 ± 8.5 years), 370 were women and 189 were men. Knee ROM showed the greatest change during the first 12 weeks after TKR, plateauing by 26 weeks. For an average patient, knee flexion increased from approximately 100º 2 weeks post TKR to 117º 52 weeks post TKR. Knee extension increased from approximately 3º knee flexion 2 weeks post TKR to 1º flexion 52 weeks post TKR. Conclusions: The results showed that the maximum gains in knee ROM should be expected within the first 12 weeks with small changes occurring up to 26 weeks after TKR. In addition, age and presurgery knee ROM are associated with the gains in knee ROM and should be factored into the estimation of expected knee ROM at a given follow-up interval after TKR.

Orthopaedic Surgeon Density in West Virginia

West Virginia (WV) has many healthcare disparities and access barriers. For bone and joint disorders, WV has some of the highest rates of musculoskeletal problems, including the highest reported rate of adult arthritis in the nation (36.2%). We hypothesized that WV has one of the lowest orthopaedic surgeon densities in the country, which can negatively impact the delivery of musculoskeletal care. Using the WV Board of Medicine practitioner databank, the Veterans Administration practitioner data, and national Orthopaedic surgeon census data, we demonstrated a considerably low orthopaedic surgeon density in WV (7.71/100,000 population versus the national average of 8.51/100,000 population) with 54% of our counties (n=30) having no Orthopaedic surgeons. This data is currently being used to further determine the appropriate allocation of resources to help improve access to specialized orthopaedic care in our state.