Vinod Dasa

Introduction: Total knee arthroplasty (TKA) patients undergo intraarticular (IA) injections before surgery to reduce pain, improve function, and delay surgery. The purpose of this study was to determine the relationship between different types of IA injection exposure and preoperative and postoperative outcomes. Methods: We reviewed a series of 321 patients who underwent primary TKA from 2016 to 2022, excluding patients with contralateral TKA within 6 months. Patients were categorized by IA injection type—ketorolac, triamcinolone, or no injection—received within 6 months of TKA. Main outcomes were the Knee Injury and Osteoarthritis Outcome Score (KOOS), and opioid prescriptions received before and 3 months after TKA. Results: Most of the 321 patients were female (64%) and White (62%). Of the 321 patients who underwent TKA, 113 (35%) received ketorolac, 64 (20%) received triamcinolone, and 144 (45%) received no injections. Significant differences in preoperative KOOS pain and ADL scores ( P = 0.021 and P = 0.047) were observed among groups. Triamcinolone was associated with significantly less preoperative pain ( P = 0.016) and greater function ( P = 0.046) than ketorolac. No significant differences were found between groups in any KOOS subscale at 3 months post-TKA. Opioid prescriptions, refills, and total morphine milligram equivalents did not differ between injection groups. Conclusion: Triamcinolone IA injections were associated with less pain and greater function before TKA than ketorolac. Future studies should include prospective studies, stratified by severity of knee osteoarthritis, to investigate whether exposure to IA injections has a favorable risk-benefit profile, accounting for osteoarthritis disease progression and heterogeneity.

This study compared the six-month medical/pharmacy costs and healthcare resource utilization (HCRU) for knee OA patients undergoing intra-articular therapy with different classes of hyaluronic acid (HA) (by molecular weight) or corticosteroid (ICS). Patients across high molecular weight (HMW) HA, medium molecular weight (MMW) HA, low molecular weight (LMW) HA, and ICS therapy groups were matched from a U.S. claims database (Optum's de-identified Clinformatics Data Mart Database), with a final size of 6,234 patients per group. Adjusted six-month medical/prescription costs per patient per month (PPPM), and HCRU rates and costs, were determined. Secondary endpoints included complication rates and adjusted costs, new prescription analgesic use, and adjunctive/supplemental intra-articular treatment. Mean adjusted PPPM medical costs were highest for LMW HA ($527.14), followed by HMW HA ($469.35) and MMW HA ($441.97) (p < .001), and lowest for the ICS group ($240.26; p < .001). Office visit, arthrocentesis, and subsequent ICS/arthrocentesis rates and corresponding costs, as well as costs for any complications, decreased from LMW HA to MMW HA to HMW HA. The ICS group had greater arthrocentesis, subsequent ICS/arthrocentesis, and office visit costs versus MMW and HMW HA groups. The ICS group had higher rates of new prescription analgesic use (15.8% versus 11.7%-12.2%) and adjunctive ICS (21.8% vs. 9.4%-11.1%) and HA (14.1% versus 1.6%-5.3%) treatment than the HA groups. HMW HA had the lowest rates of adjunctive non-index HA treatment. Claims data contains limited clinical data and relied on the accuracy of coding of diagnoses and procedures. Among HA products, HMW HA may provide greater short-term clinical and economic benefits. Additionally, intra-articular HA therapy may provide improved short-term clinical and economic results over ICS, in terms of lower rates of adjunctive intra-articular treatments, HCRU, and new prescription analgesic use. Complication rates were low reflecting the safety profiles of HA and ICS.

Background Newer analgesic techniques to reduce opioid use and pain after total knee arthroplasty (TKA) include preoperative cryoneurolysis, adductor canal block (ACB), and local anesthetic infiltration between the popliteal artery and capsule of the knee (iPACK) block. The purpose of this study was to evaluate whether changing the regional analgesic from ropivacaine to liposomal bupivacaine would provide superior pain relief and reduce opioid requirements at 2 and 12 weeks following TKA. Methods We conducted a retrospective medical records review of 140 consecutive patients who underwent primary TKA at a single site and received ACB with ropivacaine (multimodal-ropivacaine [MM-R] group, n=70) or ACB/iPACK with liposomal bupivacaine (multimodal-liposomal bupivacaine [MM-LB] group, n=70). The primary outcomes were the morphine milligram equivalent (MME) of filled opioid prescriptions at discharge and during the first 12 weeks after TKA, as well as the Knee injury and Osteoarthritis Outcome Score and the Patient-Reported Outcomes Measurement Information System pain intensity and pain interference scores at 2 and 12 weeks postsurgery. Results The median MMEs for discharge opioid prescriptions and all opioid prescriptions were, respectively, 65% (PP<0.0001) lower for patients in the MM-LB group vs the MM-R group. The MM-LB group had significantly better patient-reported outcomes 2 weeks after TKA compared to the MM-R group. Conclusion Compared with ropivacaine-based regional analgesia, liposomal bupivacaine–based regional analgesia in the context of a modern multimodal pain regimen may reduce opioid requirements and improve patient-reported outcomes during acute and short-term recovery after TKA.

Background: Osteoarthritis (OA) is the leading cause of disability among US adults and most commonly affects the knee. Guidelines for knee OA treatment include behavioral, nonpharmacological, pharmacological, and surgical interventions. While emerging knee OA treatments show promise for pain control, data gaps remain regarding the efficacy, safety, comparative effectiveness, and real-world value of treatments. Objectives: The Innovations in Genicular Outcomes Registry (IGOR) is prospectively collecting real-world data to assess clinical effectiveness, safety, health-related quality of life, and healthcare resource utilization of knee OA treatments. Design: The IGOR is a prospective, observational, longitudinal, multicenter registry (NCT05495334) examining knee OA pain treatment outcomes at intervals up to 18 months after treatment. Methods and analysis: All clinical management decisions are made via shared decision-making involving both the physician and the patient. Index joint-directed treatments may include various intra-articular injections, oral opioid and nonopioid medications (including nonsteroidal anti-inflammatory drugs), cryo nerve blocks, radiofrequency ablations, novel treatment modalities, other physical therapy modalities (including muscle strengthening), and total knee arthroplasties. Patient-reported assessments along with physician-provided medical record data are recorded. Regular data quality assessments are conducted for each site, and an outside monitor ensures data quality and integrity. A steering committee ensures transparency and oversees administrative, legal, ethical, and scientific decisions. Treatment outcomes within and between therapies are compared. Ethics: Ethical approval was granted by Advarra, Inc. (protocol number, Pro00050981). Discussion: Data from the IGOR registry study will further elucidate the effectiveness, safety, and real-world value of knee OA treatments individually or in combination. Characterization of real-world treatment patterns will help better understand the impact of specific treatments. Trial registration: Clinicaltrials.gov, NCT05495334.

Osteoarthritis (OA) is a prevalent condition that affects nearly 528 million people worldwide, including 23% of the global population aged ⩾40, and is characterized by progressive damage to articular cartilage, which often leads to substantial pain, stiffness, and reduced mobility for affected patients. Pain related to OA is a barrier to maintaining physical activity and a leading cause of disability, accounting for 2.4% of all years lived with disability globally, reducing the ability to work in 66% of US patients with OA and increasing absenteeism in 21% of US patients with OA. The joint most commonly involved in OA is the knee, which is affected in about 60%–85% of all OA cases. The aging population and longer life expectancy, coupled with earlier and younger diagnoses, translate into a growing cohort of symptomatic patients in need of alternatives to surgery. Despite the large number of patients with knee OA (OAK) worldwide, the high degree of variability in patient presentation can lead to challenges in diagnosis and treatment. Multiple society guidelines recommend therapies for OAK, but departures from guidelines by healthcare professionals in clinical settings reflect a discordance between evidence-based treatment algorithms and routine clinical practice. Furthermore, disease-modifying pharmacotherapies are limited, and treatment for OAK often focuses solely on symptom relief, rather than underlying causes. In this narrative review, we summarize the patient journey, analyze current disease burden and nonsurgical therapy recommendations for OAK, and highlight emerging and promising therapies—such as cryoneurolysis, long-acting corticosteroids, and gene therapies—for this debilitating condition.

Aims & Objectives: The purpose of this study was to identify patient characteristics associated with engagement and completion of physical therapy (PT) following total knee arthroplasty (TKA) and examine the relationship between number of PT sessions attended and outcomes during the first 12 weeks after surgery. Methods: Patients underwent unilateral primary TKA by a single surgeon and were advised to complete 17 PT sessions over 6 weeks at a hospital-affiliated facility. Analyses examined predictors of PT engagement (attendance of ≥2 sessions) and completion (attendance of 17 ± 1 sessions) within 6 weeks and associations between number of PT sessions attended and changes in range of motion (ROM) and Knee Injury and Osteoarthritis Outcome Score (KOOS) values. Results: Patients living <40 km were more likely to be engaged in PT than those living ≥40 km from the clinic ( P < .0001). Among patients who completed PT within 6 weeks, 95.0%, 85.1%, and 56.4% achieved flexion of, respectively, ≥90°, ≥100°, and ≥110°. Among engaged patients, the active flexion thresholds of ≥90°, ≥100°, and ≥110° were achieved by, respectively, 94.4%, 82.5%, and 58.1% by 6 weeks and by 96.7%, 92.1%, and 84.2% by 12 weeks. Improvement in KOOS Symptoms ( P = .029), Function in daily living ( P = .030) and quality of life ( P = .031) linearly decreased as number of PT sessions increased. Conclusions: These results raise the question of whether patients who meet satisfactory outcomes before completing 6 weeks of prescribed PT and those who attend more PT sessions than prescribed may be over-utilizing healthcare resources without additional benefit.

We queried the American Academy of Orthopaedic Surgeons American Joint Replacement Registry for primary TJA conducted between 2018 and 2020. Multivariable logistic regression was conducted to investigate the effects of region, season, or their interaction on the risk of complications within 90 days and the risk of revision surgery within 1 year after adjusting for race, surgery year, age group, procedure, and Charlson Comorbidity Index score. Unmeasured variables including hospital volume and surgeon ability were controlled for as nested random effects in the model. Bonferroni-adjusted LSMeans were used to compare each season, region, and season within each region. The risk of complications in the West was significantly higher than in the Northeast (aOR = 2.76, P < 0.001), Midwest (aOR = 2.44, P < 0.001), or South (aOR = 3.33, P < 0.001). The West also had a significantly higher risk of revision surgery than the South (aOR = 1.27, P = 0.038). These trends held across each season. Fall procedures had a significantly lower risk of both complication and revision surgery than those in the summer (aOR = 0.85, P < 0.001; aOR = 0.77, P < 0.001) or winter (aOR = 0.89, P = 0.024; aOR = 0.73, P < 0.001). Analysis of regional-seasonal interaction found that within the Northeast, fall surgeries had a significantly lower risk of revision surgery than spring surgeries (aOR = 0.64, P = 0.003). Our study found a statistically significant increase in the risk of complication in the West compared with the Northeast, Midwest, and South. Patients in the South also had a demonstrably lower risk of revision surgery than those in the West. Seasonally, fall TJA operations demonstrated a lower risk of both complication and revision surgery compared with summer or winter operations.

Purpose: Modern multimodal analgesia has been shown to significantly reduce opioid use following total knee arthroplasty (TKA). This study was conducted to determine if changing TKA discharge opioid prescriptions from automatic to upon request resulted in more opioid free recoveries without compromising pain control.Methods: Between December 2019 and August 2021, an orthopedic surgeon performed 144 primary unilateral TKAs; patients received the same multimodal analgesia protocol except for postoperative opioid prescribing. The first consecutively‐treated cohort automatically received an opioid prescription following discharge (automatic group) and the second cohort received opioid prescriptions only upon request (upon request group). Opioid prescription data were derived from a prescription monitoring program and patient‐reported outcomes (PROs) were collected preoperatively and at 2 and 12 weeks postoperatively.Results: A higher percentage of the upon request group was opioid free 3 months after TKA compared with the automatic group (55.6% vs 4.3%, p < 0.0001) without compromising pain or function. Among opioid‐naïve patients, 72% in the upon request group were opioid free after TKA compared with 5.4% in the automatic group. Opioid prescribing was not significantly reduced among opioid‐experienced patients regardless of the pain protocol.Conclusion: Requiring patients to request opioid prescriptions following TKA resulted in a higher rate of opioid free TKA, especially among opioid‐naïve patients, without increasing pain compared with offering all patients an initial opioid prescription.Level of evidence: Level III.