Larwa, Joseph

Background: Total knee arthroplasty (TKA) and hindfoot reconstruction (HFR) are often used to treat osteoarthritis and deformities of the knee and hindfoot. Despite the proven clinical effectiveness of these treatments, postoperative patient dissatisfaction is high. The knee and ankle are adjacent joints in the lower extremity, and angular deformity of either joint is known to affect positioning of the anatomical and mechanical axes of the entire limb. Although it is understood this relationship exists, there are limited studies evaluating outcomes of ipsilateral procedures on patients with pathologies of both knee and hindfoot. This article aims to evaluate whether TKA or TAA/HFR sequencing influences postoperative outcome. The study hypothesis is that TKA prior to TAA/HFR results in lower reoperation. Methods: A retrospective chart review using Current Procedural Terminology ( CPT ) codes was performed encompassing all patients who underwent TKA in conjunction with a variety of hindfoot procedures. All procedures were performed at a single academic medical site between 2000 and 2022. Exclusion criteria included those patients not having both ipsilateral TKA and hindfoot procedures or those lacking conclusive postoperative data. The primary outcome of this study was to identify significant reoperations such as adjacent joint arthrodeses, hardware removal, or unrelated ipsilateral limb surgery. Secondary outcomes included identification of revision procedures including revision TKA or revision HFR and other postoperative complication data. Results: This study included 158 patients, with 79 patients in each group. In the TKA-first group, the mean follow-up time was 10.24 years (range, 1.10-22.42 years) and the mean time to HFR was 5.94 years. In the HFR-first group, the mean follow-up time was 9.01 years (range, 1.01-23.55 years) and the mean time to TKA was 5.51 years. In patients who underwent TKA first, the mean reoperation rate was not significantly different from those who underwent HFR/TAA first, 30.4% vs 19.0% ( P = .12). In patients who underwent TKA first, the rate of HFR reoperations (22.78%) was greater than TKA reoperations (7.59%) ( P < .01). The revision rate was higher in the TKA-first group (17.7%) when compared to the HFR-first group (6.3%) ( P = .03). Additionally, there were more revision HFR procedures in the TKA-first group (9/79) compared with the HFR-first group (1/79) ( P = .009). Conclusion: In contrast to the study hypothesis that TKA first would result in less reoperation, our study found that TAA or HFR performed before TKA had an overall lower complication rate. However, these findings should be interpreted cautiously as the sample size was limited. Level of Evidence: Level III, retrospective cohort study.

Background As no consensus exists on the optimal postoperative rehabilitation protocol in terrible triad injuries, we sought to characterize the reported protocols and relate them to postoperative range of motion (ROM) measures and Mayo Elbow Performance Score (MEPS). Methods A systematic review was performed by searching PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles on the operative treatment of terrible triad injuries reporting postoperative rehabilitation protocols were included. Included studies were descriptively summarized. Methodologic quality was assessed using the Methodological Index for Non-randomized Studies criteria. Meta-analysis compared postoperative ROM measures and the MEPS between patients initiating passive ROM exercises at ≤7 days vs. >7 days. Results Our review included 36 articles with 1123 elbows (66% male, mean age: 43 years, follow-up: 27 months). Of the studies reporting physical therapy protocols, it was most commonly initiated at 7 days postoperatively (6/36, 17%), passive ROM exercises at 7 days (3/25, 12%), and active ROM at 21 days (4/26, 15%). On meta-analysis, early passive ROM initiation was not associated with improved elbow ROM or MEPS. Discussion While rehabilitation protocols commonly advised passive ROM at one week post-operatively, meta-analysis did not support functional benefits of early passive ROM. Study design Systematic Review; Level of evidence, 4.