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What follows are highlights from these studies:

Limiting Use of Tourniquets During Knee Replacement Surgery Improves Patient Outcomes

Tourniquets have traditionally been used during TKA to reduce blood loss and the need for transfusions. However, a new study of almost 18,000 patients from 2019 to 2023 found that prolonged tourniquet use was linked to increased pain, higher opioid use, and a longer recovery. 

“We found that limiting tourniquet use was associated with slightly lower rates of opioid use to control pain after surgery and a quicker ability to complete physical therapy and leave the hospital,” said Brian P. Chalmers, MD, hip and knee surgeon at HSS and co-senior author of the study.

Thanks to advances in medicine and technology, tourniquets may not be needed as often. For example, tranexamic acid (TXA) is now commonly used to effectively reduce bleeding and lower the likelihood of patients requiring a blood transfusion.

“If you have a drug that has this beneficial effect, then the need for a tourniquet may be reduced,” explained Alejandro Gonzalez Della Valle, MD, hip and knee surgeon at HSS and co-senior author of the research. “If you limit tourniquet use, patients will hurt less and will move sooner, and that will allow patients to go home sometimes the same day.” 

Dr. Della Valle notes that limiting tourniquet use can also reduce opioid consumption. The reason that tourniquet use during TKA has been associated with increased post-operative pain is because the device compresses the quadricep and hamstring muscles to restrict blood flow during the operation. The increased pain may impact the time it takes to complete rehabilitation.

Surgeons have also traditionally used tourniquets to keep the area between the knee implant and the bone as dry as possible, which helps bone cement create a stronger bond between the bone and the implant, potentially reducing the risk of loosening over time.

“Recent studies have shown that you can obtain a dry field without using a tourniquet, reducing its necessity during TKA,” explained Dr. Chalmers.  

Another development that has lessened the need for the use of tourniquets is cementless fixation, in which a specially-designed implant that allows the bone to grow into the implant and achieve long-term fixation without the use of cement.

There is currently no consensus in the literature or among surgeons throughout the country on the use of tourniquets during TKA. Surgeons use these devices differently based on individual patient needs. Some use a tourniquet from the time of incision until the implant is fixated to the bone, while others use it only during cementation or throughout the entire procedure until the wound is closed and the dressings are in place. Some surgeons may opt not to use a tourniquet at all. 

“What sets this study apart is that it captures what surgeons are doing in their daily practice,” said Dr. Chalmers. “To our knowledge, this is the only paper that addresses several different ways surgeons use tourniquets during TKA, including no usage, limited usage, and full usage.”

The study’s authors conclude that reduced tourniquet use should be considered within the realm of multiple advances that help patients recover faster after surgery and with less pain. These include newer drugs and tools used to reduce pain and blood loss during surgery, two major factors that often prolong hospital stays.

“Any measures we can take around the time of surgery to help those factors can significantly improve patient outcomes,” said Dr. Della Valle.

NSAIDs Reduce Risk of Fibrosis Needing Further Treatment after Knee Replacement Surgery

A new study led by surgeons at HSS shows that patients who were prescribed a non-steroidal anti-inflammatory drug (NSAID) after TKA had a reduced risk of developing painful scar tissue, a condition known as arthrofibrosis, which often requires additional procedures. The findings also shed light on the durations for NSAID use to prevent fibrosis following surgery.

In arthrofibrosis, excessive scar tissue forms in and around a joint after an operation. It can lead to stiffness, pain and reduced range of motion in the joint. Approximately 2% to 6% of patients require a minimally invasive procedure called manipulation under anesthesia (MUA) to treat this complication.

The researchers found that patients who were prescribed an NSAID had a significantly lower incidence of MUAs (5.3%) 90 days after surgery compared to those who did not have an NSAID prescription (12.6%). The study included more than 23,000 people who had TKA at HSS between 2017 and 2021.

“This study highlights the importance of NSAID use for early recovery after TKA,” says Peter K. Sculco, MD, hip and knee surgeon at HSS and senior author of the study. “These medications are associated with lower rates of fibrotic pain and stiffness requiring an intervention such as MUA.”

He added that decreased risk was not seen in patients who used NSAIDs for more than four weeks, suggesting patients stop within one month’s time to get the most benefit.

Some patients, however, cannot use NSAID medications due to risk of bleeding or gastrointestinal or kidney issues.

“We now use steroids for one week after TKA in patients who are unable to take NSAIDs,” explained Dr. Sculco. “However, further research is necessary to determine the effect of steroids on MUA rates and the appropriate dose and duration for this group of patients.”

Local Anesthetic Leads to Better Patient Outcomes after Revision Knee Replacement Surgery

A new study led by surgeons at HSS found that the use of a new local anesthetic at the time of revision TKA enabled patients to leave the hospital sooner and recover faster.

According to the findings, a recently introduced pain medication known as extended-release, dual-acting local anesthetic (ERDALA) used at the time of aseptic revision TKA was associated with better patient outcomes. These included completing physical therapy sooner, shorter hospital stays, and more patients being discharged within one day after surgery.

Approximately 5% to 10% of patients need aseptic revision TKA, a surgical procedure done to address loosening, stiffness, or instability of a non-infected knee joint that was previously replaced with TKA.

The study reviewed outcomes of 171 patients who had aseptic revision TKA at HSS between January 2021 and May 2023. Patients either received ERDALA (51.5%) or standard of care periarticular injections (PAI) (48.5%) during surgery. The researchers found that patients who received ERDALA went home nearly a day sooner and cleared physical therapy approximately 20 hours faster than those who received PAI.

“ERDALA did not reduce pain scores or the total amount of opioids prescribed in this study but was associated with helping patients reach early recovery milestones sooner,” noted Dr. Peter Sculco, who is also senior author of this study. “This medication can be a valuable tool in rapid recovery strategies used in aseptic revision TKA, which can lead to patients walking better and getting home faster.”

He added that further research is needed to explore these strategies in the revision population, especially as more revision surgeries are performed in the outpatient setting.

HSS is the world’s largest academic medical center specialized in musculoskeletal health, spanning orthopedics, rheumatology and related disciplines. The HSS Research Institute maintains 20 laboratories dedicated to solving debilitating orthopedic and rheumatic conditions such as arthritis, bone and soft tissue injuries, autoimmune diseases, and musculoskeletal pain and deformities. There, more than 300 dedicated personnel focus on tissue repair, improving surgical outcomes, autoimmunity and inflammation, genomics, new treatments, and precision medicine.

“HSS has a long history of contributing to the collective base of clinical and basic science knowledge and finding healthcare solutions for complex conditions,” said Louis A. Shapiro, President and CEO, HSS. “We’re proud that through the joint efforts of our institution and philanthropic support, we will have the ability to make a strong impact on this growing and vital area of research.”

“As experts in inflammatory disorders and in the development of interventions for overactive immune responses, the clinicians and researchers at HSS are well-positioned to investigate many of the adverse effects of COVID-19,” says Lionel B. Ivashkiv, MD, Chief Scientific Officer at the HSS Research Institute. “This includes studying the causes of these adverse effects as well as how to prevent and treat them.”What follows are descriptions of the first group of funded projects in basic/translational research:

Activation of pDCs by SARS-CoV-2 and Its Impact on Macrophage Response

Principal Investigator: Franck Barrat, PhD

Co-Investigator: Marie-Dominique Ah Kioon, PhD

This project will study cell types that are responsible for cytokine storm syndrome — the hyperactive immune response seen in people with COVID-19 — by looking at how certain immune cells are activated by SARS-CoV-2. Research in mice infected with SARS-CoV, a coronavirus similar to the one that causes COVID-19, has suggested that plasmacytoid dendritic cell precursors (pDCs) are key to the immune response to infection. These pDCs activate macrophages, which in turn secrete cytokines. In the SARS-CoV research, depletion of pDCs appeared to protect the mice from lethal lung injury. Using blood samples from donors, the investigators will study the pathway by which pDCs activate macrophages and look at ways to therapeutically block that process.

Inhibiting RNA Polymerase II Transcription Complexes in Macrophages to Target COVID-19–Associated Cytokine Storm

Principal Investigator: Inez Rogatsky, PhD

Co-Investigators: Steven Josefowicz, PhD, and Robert P. Fisher, MD, PhD

This pilot project will dissect the role of macrophages in SARS-CoV-2-induced acute respiratory distress syndrome (ARDS), the main driver of COVID-19-associated mortality. We will test small-molecule inhibitors of RNA Polymerase II (Pol II) transcription complexes for their ability to modulate type I interferon and inflammatory pathways in monocytes/macrophages. This research will be done using cultured macrophages as well as donor blood and blood from COVID-19 patients.

Mechanisms of Cytokine Storm in Patients with COVID-19

Principal Investigator: Mary K. Crow, MD

Co-Investigators: Mikhail Olferiev, MD, and Lionel B. Ivashkiv, MD

The objectives of this study are to describe the process of the cytokine storm in people with COVID-19 and to identify biologic predictors of a favorable outcome in patients with severe cases of the disease. The project aims to characterize immune cell populations seen in COVID-19 patients who experience cytokine storm and compare them to those patients who do not, to compare the immune response before and after patients are given the anti-inflammatory drug anakinra, and to identify measures that suggest patients are more likely to decline and eventually require mechanical ventilation. The research will employ blood samples from HSS patients who are being treated for COVID-19 at New York–Presbyterian Hospital and who meet certain other qualifications.

What follows are descriptions of the first group of funded projects in the areas of clinical and health outcomes research:

Response to and Recovery from TKA in Patients with Antibodies to SARS-CoV-2

Principal Investigator: Miguel Otero, PhD

Co-Investigators: Meghan Kirksey, MD, PhD, and Peter K. Sculco, MD

It is unknown if people who have been exposed to COVID-19 may be at higher risk of experiencing an abnormal immune response following surgery, resulting in poor outcomes. This study will evaluate the response to and recovery from total knee arthroplasty (TKA) in people who have antibodies to COVID-19 — a marker of exposure. This study will include both patients who have COVID-19 antibodies and those who don’t, to act as controls. Patients will be followed for six weeks after surgery and evaluated for the presence of certain immune markers in the blood, as well as symptoms of inflammation including pain and stiffness in the joint.

SARS-CoV-2 Exposure and the Role of Vitamin D Among Hospital Employees

Principal Investigator: Emily M. Stein, MD, MS

Co-Investigators: Theresa T. Lu, MD, PhD; Andy O. Miller, MD; Jeri Nieves, PhD; and Alana Serota, MD

It is unknown if people with vitamin D deficiency may be more likely to become infected with COVID-19. This study will investigate vitamin D status and associated immune markers as risk factors for COVID-19 infection in a cohort of healthcare workers. Healthcare workers are at higher risk of contracting COVID-19 than the general population, making them a good group to study. Vitamin D is critical for immune function and is known to be protective against respiratory-tract infection and tuberculosis. This prospective, observational study will follow healthcare workers at HSS and at other healthcare facilities for one year, to determine whether levels of vitamin D and certain immune cells in the blood make someone more susceptible to COVID-19 infection.

Association of Immunomodulatory Medication Use and Social Determinants of Health with COVID-19 Infection in Systemic Rheumatic Disease Patients in New York City

Principal Investigator: Medha Barbhaiya, MD, MPH

Co-Investigators from HSS: Lisa Mandl, MD, MPH; Catherine MacLean, MD, PhD; Vinicius Antao, MD, PhD; Jane Salmon, MD; and Mayu Sasaki, MPH

Other Co-Investigators: Candace Feldman, MD, MPH (of Brigham and Women’s Hospital); Debra D’Angelo, MS (of Weill Cornell Medicine)

Using data from the INSIGHT Clinical Research Network, a central repository containing longitudinal electronic health data for residents of New York City, investigators will assemble a cohort of patients being treated with immunomodulatory medications for rheumatic disease. This patient population will then be used to study the effect of these medications on COVID-19 incidence and outcomes. Retrospective data will be used to evaluate the incidence and severity of COVID-19 in these patients. Patients will also be studied prospectively to determine whether there’s a relationship between COVID-19 infection and future rheumatic disease as well as to study connections between infection and future psycho-social issues.

Assessment of Surgical Outcomes in the COVID-19 Pandemic Era

Principal Investigator: Andy O. Miller, MD

Co-Investigators: Scott A. Rodeo, MD, and Mark Fontana, PhD

Investigators will implement a patient registry to evaluate how COVID-19 affects outcomes and complication rates after orthopedic surgery. This registry, along with COVID-19 screening procedures, will provide the tools to address specific research questions. Among these questions are determining the incidence of current and prior infection among the HSS surgical population, the clinical features associated with current and prior infections in this patient population, and whether COVID-19 status affects short-term complication rates.

What follows is a description of an integrated multidisciplinary study being undertaken jointly by the Adult Reconstruction and Joint Replacement (ARJR) Perioperative Research Group, Anesthesiology and Rheumatology:

Prediction and Prevention of Postoperative Blood Clots in COVID-19 Patients

Principal Investigators: Friedrich Boettner, MD; Kethy M. Jules-Elysee, MD; Lisa A. Mandl, MD, MPH

Co-Investigators: ARJR surgeons: Alejandro Gonzalez Della Valle, MD; Jason Blevins, MD; David J. Mayman, MD; Peter K. Sculco, MD; Geoffrey H. Westrich, MD and Thomas P. Sculco, MD

Medicine/Rheumatology: Medha Barbhaiya, MD, MPH; Doruk Erkan, MD, MPH; Deanna Jannat-Khah, DrPH

Pathology: Thomas W. Bauer, MD, PhD

Anesthesiology: Stavros G. Memtsoudis, MD, PhD, MBA; Alexandra Sideris, PhD

ARJR: Amethia Joseph, MHA; Ethan Krell, MS

Weill Cornell Medicine: Raymond David Pastore, MD

Recent literature suggests that one of the major complications seen in people with COVID-19 is thrombosis (the formation of blood clots) due to endothelial dysfunction, persistent inflammation and potentially antiphospholipid antibodies. As elective surgeries resume, those with prior exposure to SARS-CoV-2 will inevitably present for treatment, and some may have perioperative management considerations related to their risk of deep-vein thrombosis. This project will use, a noninvasive device that can determine clotting risks, to investigate whether people who have had COVID-19 have a more dysfunctional endothelium preoperatively and at 24 hours after surgery. The investigators will measure antiphospholipid antibodies and inflammatory markers, and evaluate the prevalence of asymptomatic post-operative deep-vein thrombosis in people who undergo TKR and have SARS-CoV-2 antibodies.

COVID-19 Translational Research Core at HSS

Principal Investigator: Theresa Lu, MD, PhD

Co-Investigators: Jessica Andrés-Bergós, PhD; Miguel Otero, PhD and Emily M. Stein, MD, MS

The COVID-19 Translational Research Core (TRC) was designed to fill critical gaps in the resources needed to promote the broad range of COVID-19–related clinical and translational research at HSS. The TRC will provide consultation on the design and implementation of COVID-19 research in the areas of orthopedics, rheumatology and metabolic bone disease; support for a COVID-19 biobank; and technical expertise and facilities required for clinical and translational researchers working on COVID-19–related projects. The TRC staff will help to acquire, house, and track biospecimens from investigator-initiated COVID-19–related research studies.

In 2018, TKA was removed from the Center for Medicare and Medicaid Service inpatient-only procedure list, which may result in more of these surgeries being conducted as ambulatory procedures.

“Fast-track joint arthroplasty is feasible. However, I’m always concerned about prematurely discharging a patient, should something bad happen and the patient either will not or cannot handle the situation appropriately,” said Jiabin Liu, MD, PhD, lead investigator of the study and anesthesiologist at HSS.

To find out if same-day discharge joint arthroplasty is associated with an increased risk for adverse outcomes or unplanned readmission, Dr. Liu and colleagues at HSS conducted a population-based observational study of patients who underwent primary TKA or primary THA between 2011 and 2017 with data from the American College of Surgeons-National Surgical Quality Improvement Program^® (ACS NSQIP^®), which tracks surgeries performed in hospitals, not ambulatory surgery centers.

The researchers divided the patients into three groups according to length of stay (LOS 0, 1, and 2-3 days) and conducted regression analysis and propensity score matching. The primary outcomes they examined were readmission incidence and cardiac and/or pulmonary complications within 30 days of surgery, and the secondary outcomes examined were infections, major complication, and any complication.

The researchers found that between 2011 and 2017, there was an increase in the number of patients discharged on the day of surgery or the day after surgery (TKA: 1.04% in 2011 vs 26.55% in 2017; THA: 3.44% in 2011 vs 34.91% in 2017). There were no differences in 30-day mortality and no statistical differences in unplanned readmissions in patients undergoing TKA or THA who were released on the day of or the day after surgery. However, after adjusting for variables such as known risk factors prior to surgery, release on the day of surgery was associated with higher risk for cardiac and pulmonary complications in both TKA and THA when comparing to patients discharged the day after surgery.

“We did not expect same-day discharge patients to carry such high odds of complications compared with the fast-tracked group,” said Dr. Liu. “While the overall burden of complications is relatively low, until future studies can confirm or challenge our findings, a measured approach is advisable when recommending discharge of patients on the same day of surgery.”

While Dr. Liu emphasized that these results need confirmation from future studies, this study can currently alert and inform patients, clinicians, and policy-makers that patient selection is important for same-day surgery.

“When considering whether they want to be discharged the day of surgery, patients should keep in mind whether they have the knowledge, support, and necessary resources at home or close by in case they need medical attention. This does not necessarily have to be in person; telemedicine may potentially help,” Dr. Liu said.

“Clinicians need to realize that not all patients are suitable for ambulatory joint arthroplasty,” said Dr. Liu. “Existing prediction models based on risk factors are not reliable, while at least 50% of these fast-tracked patients with complications do not carry these risk factors.”

Reference:

Liu J, Elkassabany NM, Poeran J, Gonzalez Della Valle A, Kim DH, Maalouf DB, Memtsoudis SG. “Same day discharge total joint arthroplasty is associated with increased risk of perioperative complications: a population-based study.” Presented at: 44th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), April 11-13, 2019; Las Vegas, NV.

HSS hip & knee surgeon Alejandro Gonzalez Della Valle, MD, said that surgeons have already been turning away from powerful anticoagulants toward aspirin and non-drug options for thwarting clots.

Additionally, he added that patients generally have a low risk of blood clots due to shorter surgical times and the use of regional anesthesia.

In general, Dr. Della Valle advised that patients should talk to their surgeons about their risk of developing blood clots and what measures will be taken to lower it.

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Additional Coverage:

• U.S. News & World Report: Aspirin as Good a Clot Buster as Pricey Drugs After Joint Replacement