The rise of improved perioperative recovery protocols after total knee arthroplasty (TKA) has led to faster, more streamlined hospital stays for many patients. Combined with the implementation of value-based care and bundled payment initiatives, there has been a paradigm shift toward outpatient TKA surgery. This change to practice has been accelerated by recent policy changes enacted by the Center for Medicaid and Medicare Services regarding the removal of TKA as an inpatient only procedure as well as some insurance companies denying preauthorization for inpatient stays after TKA. Our review aims to address the inclusion and exclusion criteria for outpatient TKA consideration, examine the outcomes for outpatient joint replacement surgery, and discuss limitations of widespread adoption for same-day discharges.
The objective of this study is to compare the cyclic loading strength and ultimate failure load in suture anchor repair versus transosseous tunnel repair of patellar tendons using a cadaver model. Twelve cadaveric patella specimens were used (six matched pairs). Dual-energy X-ray absorptiometry (DXA) measurements were performed to ensure equal bone quality among groups. All right knees were assigned to the suture anchor repair group ( = 6), whereas all left knees were assigned to the transosseous bone tunnel group ( = 6). Suture type and repair configuration were equivalent. After the respective procedures were performed, each patella was mounted into a gripping jig. Tensile load was applied at a rate of 1 Hz between magnitudes of 50 and 150 N, 50 and 200 N, 50 and 250 N, and tensile load at a rate of 0.1 mm/s until failure. Failure was defined as a sharp deviation in the linear load versus displacement curve, and failure mode was recorded. DXA measurements demonstrated equivalence of bone quality between the two groups ( > 0.05). During cyclic load testing, there was only a statistically significant difference between the groups with regard to cyclic loading at the 50 to 200 N loading cycle ( = 0.010). There was no statistically significant difference between the groups with regard to ultimate load to failure ( = 0.43). Failure mode within the suture anchor cohort occurred through anchor pullout except for one, which failed through the tendon. All specimens within the transosseous cohort failed through the midsubstance of the tendon except for one, which failed through suture breakage. Suture anchor repair demonstrated a similar biomechanical profile regarding cyclic loading and ultimate load to failure when compared with "gold standard" transosseous tunnel patellar tendon repair with a trend toward less gapping in the suture anchor group. Using suture anchors for repair of the patella tendon has similar biomechanical properties to transpatellar tunnels but may provide other clinical advantages.
Controversy exists regarding double-bundle (DB) versus single-bundle (SB) posterior cruciate ligament (PCL) reconstruction, with differences in multiple variables affecting biomechanical and clinical results. Our objective was to compare immediate postimplantation biomechanics of SB versus DB reconstructions to determine the relative importance of restoring both PCL bundles versus total graft volume. Twenty knees were randomly assigned to five techniques ( = 4 knees/technique), performed by three surgeons experienced in their technique(s), three SB techniques ( = 12; all-inside arthroscopic inlay, all-inside suspensory fixation, and arthroscopic-assisted open onlay), and two DB techniques ( = 8; arthroscopic-assisted open inlay and all-inside suspensory fixation). Each knee was tested in three conditions: PCL-intact, PCL-deficient, and post-PCL reconstruction. Testing consisted of a posterior-directed force at four knee flexion angles, 10, 30, 60, and 90 degrees, to measure load to 5 mm of posterior displacement, maximum displacement (at 100 N load), and stiffness. Data for each knee were normalized, combined into two groups (SB and DB), and then compared using one-way analysis of variance. Graft volumes were calculated and analyzed to determine if differences significantly influenced the biomechanical results. Intact knees were stiffer than both groups at most angles ( < 0.02; < 0.05). DB was stiffer than SB at all angles except 30 degrees ( < 0.05). Intact knees had less laxity than SB ( < 0.03) and DB ( < 0.05) at 60 and 90 degrees. DB had less laxity than SB at all angles except 60 degrees ( < 0.05). Intact knees required more load than SB at 30, 60, and 90 degrees ( < 0.01) and more than DB at 60 and 90 degrees ( < 0.05). DB required more load than SB at 30, 60, and 90 degrees ( < 0.01). Graft volumes did not have strong correlations ( = 0.13-0.37) to any measurements. Neither group of PCL reconstruction techniques was able to replicate native PCL biomechanics. DB reconstructions were biomechanically superior to SB reconstructions; they may be preferred for clinical use when immediate post-reconstruction graft strength and stability are critical. These results were not strongly influenced by graft size differences, further supporting the PCL codominance theory.
No surgical technique recreates native posterior cruciate ligament (PCL) biomechanics. We compared the biomechanics of five different PCL reconstruction techniques versus the native PCL. Cadaveric knees ( = 20) were randomly assigned to one of five reconstruction techniques: Single bundle all-inside arthroscopic inlay, single bundle all-inside suspensory fixation, single bundle arthroscopic-assisted open onlay (SB-ONL), double bundle arthroscopic-assisted open inlay (DB-INL), and double bundle all-inside suspensory fixation (DB-SUSP). Each specimen was potted and connected to a servo-hydraulic load frame for testing in three conditions: PCL intact, PCL deficient, and PCL reconstructed. Testing consisted of a posterior force up to 100 N at a rate of 1 N/s at four knee flexion angles: 10, 30, 60, and 90 degrees. Three material properties were measured under each condition: load to 5 mm displacement, maximal displacement, and stiffness. Data were normalized to the native PCL, compared across techniques, compared with all PCL-intact knees and to all PCL-deficient knees using one-way analysis of variance. For load to 5 mm displacement, intact knees required significantly ( < 0.03) more load at 30 degrees of flexion than all reconstructions except the DB-SUSP. At 60 degrees of flexion, intact required significantly ( < 0.01) more load than all others except the SB-ONL. At 90 degrees, intact, SB-ONL, DB-INL, and DB-SUSP required significantly more load ( < 0.05). Maximal displacement testing showed the intact to have significantly ( < 0.02) less laxity than all others except the DB-INL and DB-SUSP at 60 degrees. At 90 degrees the intact showed significantly ( < 0.01) less laxity than all others except the DB-SUSP. The intact was significantly stiffer than all others at 30 degrees ( < 0.03) and 60 degrees ( < 0.01). Finally, the intact was significantly ( < 0.05) stiffer than all others except the DB-SUSP at 90 degrees. No technique matched the exact properties of the native PCL, but the double bundle reconstructions more closely recreated the native biomechanics immediately after implantation, with the DB-SUSP coming closest to the native ligament. This study contributes new data for consideration in PCL reconstruction technique choice.
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