Reoperation-free survival after hip screws or hip arthroplasty for undisplaced femoral neck fractures in the elderly

Aims

Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately.

Methods

We retrieved data on all patients aged ≥ 75 years with an uFNF registered in the Swedish Fracture Register from 2011 to 2018. The database was linked to the Swedish Arthroplasty Register and the National Patient Register to obtain information on comorbidity, mortality, and reoperations. Our primary outcome, reoperation, or death at one year was analyzed using restricted mean survival time, which gives the mean time to either event for each group separately.

Results

Overall, 3,909 patients presenting with uFNFs were included. Of these patients, 3,604 were treated with IF and 305 with primary arthroplasty. There were no relevant differences in age, sex, or comorbidities between groups. In the IF group 58% received cannulated screws and 39% hook pins. In the arthroplasty group 81% were treated with hemiarthroplasty and 19% with total hip arthroplasty. At one year, 32% were dead or had been reoperated in both groups. The reoperation-free survival time over one year of follow-up was 288 days (95% confidence interval (CI) 284 to 292) in the IF group and 279 days (95% CI 264 to 295) in the arthroplasty group, with p = 0.305 for the difference. Mortality was 26% in the IF group and 31% in the arthroplasty group at one year. Reoperation rates were 7.1% in the IF group and 2.3% in the arthroplasty group.

Conclusion

In older patients with a uFNF, reoperation-free survival at one year seems similar, regardless of whether IF or arthroplasty is the primary surgery. However, this comparison depends on the choice of follow-up time in that reoperations were more common after IF. In contrast, we found more early deaths after arthroplasty. Our study calls for a randomized trial comparing these two methods.

Should All Patients Receive Extended Oral Antibiotic Prophylaxis? Defining Its Role in Patients Undergoing Primary and Aseptic Revision Total Joint Arthroplasty

BACKGROUND

Prior studies have demonstrated reduced periprosthetic joint infection (PJI) rates following extended oral antibiotics (EOAs) for high-risk patients undergoing primary total joint arthroplasty (TJA). This study compared 3-month PJI rates in all patients undergoing primary or aseptic revision TJA with or without EOA prophylaxis.

METHODS

In total, 2,982 consecutive primary (n = 2,677) and aseptic revision (n = 305) TJAs were performed by a single, fellowship-trained arthroplasty surgeon from 2016 to 2022 were retrospectively reviewed. Beginning January 2020, all patients received 7 days of 300 mg oral cefdinir twice daily immediately postoperatively. Rates of PJI at 3 months were compared between patients who received or did not receive EOA.

RESULTS

Rates of PJI at 3 months in patients undergoing primary and aseptic revision TJA were significantly lower in those receiving EOA prophylaxis compared to those who did not (0.41 versus 1.13%, respectively; P = .02). After primary TJA, lower PJI rates were observed with EOA prophylaxis utilization (0.23 versus 0.74%, P = .04; odds ratio [OR] 3.85). Following aseptic revision TJA, PJI rates trended toward a significant decrease with the EOA compared to without (1.88 versus 4.83%, respectively; P = .16; OR 2.71).

CONCLUSIONS

All patients undergoing primary or aseptic revision TJA who received EOA prophylaxis were 3.85 and 2.71 times less likely, respectively, to develop PJI at 3 months compared to those without EOA. Future studies are needed to determine if these results are maintained at postoperative time periods beyond 3 months following primary TJA.

LEVEL OF EVIDENCE

III, Retrospective review.

Metal-on-Metal Hip Arthroplasty: A Comprehensive Review of the Current Literature

Metal-on-metal (MoM) total hip arthroplasty has been widely used since the end of the 20th century, although rates have now decreased due to concerns regarding adverse reactions and failure rates. The MoM implant has been replaced with other materials, such as ceramic-on-ceramic (CoC) and metal-on-polyethylene (MoP). This literature review looks at the past and present use of MoM prostheses to assess whether the turn away from MoM use is justified. Online literature searches were performed on PubMed, Ovid Medical Literature Analysis and Retrieval System Online (MEDLINE), and Web of Science online databases using the search terms "MoM and (ARMD and ALVAL)" (ARMD: adverse reaction to metal debris; ALVAL: aseptic lymphocyte-dominant vasculitis-associated lesion). A total of 64 relevant titles were included in the review. Although risk factors for adverse reactions and the causes of ARMD are generally agreed upon, more work is required to further understand the specific thresholds of blood metal ion levels that can be used to consistently identify ARMD and excessive metal wear-debris in patients who have not had their MoM implants revised. Metal-on-metal devices are not an acceptable option for total hip arthroplasties (THAs) in their current formulation due to the high rate and risk of ARMD. Some MoM hip resurfacing operations are appropriate for very carefully selected patients who are fully aware of the risks posed by the implant. It is recommended that device-specific thresholds for metal ion levels be developed to identify patients at risk of ARMD locally and systemically while using auxiliary tools to assist diagnosis, such as metal artefact reduction sequences (MARS)-MRI and hip scoring tools. Further work should investigate device-specific blood metal ion levels, the systemic effects of raised metal ion concentrations secondary to MoM arthroprosthetic wear, and the potential risks of ARMD caused by wear from tapered stems (including the implications this has for patients with CoC and MoP prostheses).

National variation in prophylactic antibiotic use for elective primary total joint replacement

Aims

Prophylactic antibiotic regimens for elective primary total hip and knee arthroplasty vary widely across hospitals and trusts in the UK. This study aimed to identify antibiotic prophylaxis regimens currently in use for elective primary arthroplasty across the UK, establish variations in antibiotic prophylaxis regimens and their impact on the risk of periprosthetic joint infection (PJI) in the first-year post-index procedure, and evaluate adherence to current international consensus guidance.

Methods

The guidelines for the primary and alternative recommended prophylactic antibiotic regimens in clean orthopaedic surgery (primary arthroplasty) for 109 hospitals and trusts across the UK were sought by searching each trust and hospital's website (intranet webpages), and by using the MicroGuide app. The mean cost of each antibiotic regimen was calculated using price data from the British National Formulary (BNF). Regimens were then compared to the 2018 Philadelphia Consensus Guidance, to evaluate adherence to international guidance.

Results

The primary choice and dosing of the prophylactic antimicrobial regimens varied widely. The two most used regimens were combined teicoplanin and gentamicin, and cefuroxime followed by two or three doses of cefuroxime eight-hourly, recommended by 24 centres (22.02%) each. The alternative choice and dosing of the prophylactic antimicrobial regimen also varied widely across the 83 centres with data available. Prophylaxis regimens across some centres fail to cover the likeliest causes of surgical site infection (SSI). Five centres (4.59%) recommend co-amoxiclav, which confers no Staphylococcus coverage, while 33 centres (30.28%) recommend cefuroxime, which confers no Enterococcus coverage. Limited adherence to 2018 Philadelphia Consensus Guidance was observed, with 67 centres (61.50%) not including a cephalosporin in their guidance.

Conclusion

This analysis of guidance on antimicrobial prophylaxis in primary arthroplasty across 109 hospitals and trusts in the UK has identified widespread variation in primary and alternative antimicrobial regimens currently recommended.

Total hip arthroplasty using an alkali- and heat-treated titanium Zweymüller stem with no trochanteric shoulder: results at 5-year follow-up

BACKGROUND

A trochanteric shoulder is 1 of the characteristics of the original Zweymüller femoral stem for total hip arthroplasty (THA). There have been few clinical reports of THA using recently available versions of Zweymüller-type stems with eliminated trochanteric shoulder.

METHODS

82 consecutive THAs with a Zweymüller-type stem without trochanteric shoulder were analyzed. The stem was made of alkali- and heat-treated titanium, straight, tapered, with rectangular cross-section. Survivorship was estimated with the Kaplan-Meier method.

RESULTS

76 of 82 hips (92.7%) were followed for more than 5 years or until revision. 35 of 82 hips (42.7%), were revised and the predominant reason for revision was aseptic loosening of the femoral stem (34 of 35 hips, 97.1%). Survival with revision for any reason as the endpoint was 71.3% (95% CI, 51.8% to 80.1%) at 5 years.

CONCLUSIONS

The survival of the modified Zweymüller-type stem with no trochanteric shoulder was unacceptably low.

Resurfacing Egg-shell Patellar Defect in a Single-staged Primary total Knee Arthroplasty - A Case Report

Introduction

Patellofemoral biomechanics are a very critical factor for patient satisfaction after total knee arthroplasty. Patellar defects in a primary total knee arthroplasty are rare. We present a rare case of valgus deformed knee with an eroded egg-shell like patella managed with primary knee arthroplasty.

Case Report

A 58-year-old female with bilateral knee pain for 35-years presented to us with a bilateral valgus knee. The knee range of movement was restricted more on the left side and severely restricting her activities of daily living. She had an egg-shell like eroded patellar defect in an osteoarthritic knee for which, she underwent primary total knee arthroplasty and patellar resurfacing with autologous bone graft harvested from the tibial cut bone.

Conclusion

We have presented a rare case of a combination of patellar defect in an Osteoarthritic knee which was managed by modified gapbalancing technique of TKA with a novel method of patellar resurfacing in a single stage with good functional results at 1-year postoperatively. This case improves our understanding of the management of such complex scenarios and, more importantly raises the questions our understanding and need of classification of such patellar defects in a primary arthritic knee.

Intramedullary Nail or Primary Arthroplasty? A System Review and Meta-Analysis on the Prognosis of Intertrochanteric Femoral Fractures Based on Randomized Controlled Trials

Introduction

There is no consensus regarding the superiority between intramedullary nailing and primary arthroplasty in the management of intertrochanteric femoral fractures. This systematic review was performed to investigate and compare the clinical efficacy of intertrochanteric femoral fractures treated with these 2 methods.

Materials and methods

We systematically searched PubMed, Embase, Cochrane, Web of science core collection and ClinicalTrials.gov for randomized controlled trials which compared the clinical outcomes of intertrochanteric fractures treated with either intramedullary nails or primary arthroplasty. Relevant data of the postoperative complications, reoperations, mortality and functional assessment, were pooled and presented graphically.

Results

A total of 6 trials with 427 participants were identified and included in the analyses. The pooled estimates suggested these 2 techniques have comparable risks in terms of overall complications (pooled risk ratio [RR] .80; 95% confidence interval [CI] .43 to 1.43; I² = 79.94%), the rate of patients with orthopedic complications (RR .71, 95% CI .40 to 1.27; I² = .00%), reoperations (RR 1.33, 95% CI .48 to 3.71; I² = .00%), the overall mortality (RR .52; 95%CI .26 to 1.02; I² = 31.35%) and 1-year mortality (RR .67; 95%CI .38 to 1.19; I² = .00%). Primary arthroplasty associated with higher HHS at 3 months postoperatively (MD -21.95, 95% CI -28.29 to −15.60; I² = 70.44%). While the difference was not significant at 6 months (MD 2.32, 95% CI -1.55 to 6.18; I² = .00%), and even reversed at 12 months postoperatively (MD 13.02, 95% CI 8.14 to 17.90; I² = 73.42%).

Conclusions

Meta-analytic pooling of current evidences demonstrated that primary arthroplasty is related to a better early functional recovery at the early stage postoperatively, but the long-term result tends to favor to intramedullary nailing. The differences in overall complications, the rate of patients with orthopedic complications, reoperations, overall and 1-year mortality did not reach a significant level.

Progression to arthroplasty surgery among patients with hip and knee osteoarthritis : a study from the Swedish BOA Register

AIMS

The aim of this study was to estimate time to arthroplasty among patients with hip and knee osteoarthritis (OA), and to identify factors at enrolment to first-line intervention that are prognostic for progression to surgery.

METHODS

In this longitudinal register-based observational study, we identified 72,069 patients with hip and knee OA in the Better Management of Patients with Osteoarthritis Register (BOA), who were referred for first-line OA intervention, between May 2008 and December 2016. Patients were followed until the first primary arthroplasty surgery before 31 December 2016, stratified into a hip and a knee OA cohort. Data were analyzed with Kaplan-Meier and multivariable-adjusted Cox regression.

RESULTS

At five years, Kaplan-Meier estimates showed that 46% (95% confidence interval (CI) 44.6 to 46.9) of those with hip OA, and 20% (95% CI 19.7 to 21.0) of those with knee OA, had progressed to arthroplasty. The strongest prognostic factors were desire for surgery (hazard ratio (HR) hip 3.12 (95% CI 2.95 to 3.31), HR knee 2.72 (95% CI 2.55 to 2.90)), walking difficulties (HR hip 2.20 (95% CI 1.97 to 2.46), HR knee 1.95 (95% CI 1.73 to 2.20)), and frequent pain (HR hip 1.56 (95% CI 1.40 to 1.73), HR knee 1.77 (95% CI 1.58 to 2.00)). In hip OA, the probability of progression to surgery was lower among those with comorbidities (e.g. ≥ four conditions; HR 0.64 (95% CI 0.59 to 0.69)), with no detectable effects in the knee OA cohort. Instead, being overweight or obese increased the probability of OA progress in the knee cohort (HR 1.25 (95% CI 1.15 to 1.37)), but not among those with hip OA.

CONCLUSION

Patients with hip OA progressed faster and to a greater extent to arthroplasty than patients with knee OA. Progression was strongly influenced by patients' desire for surgery and by factors related to severity of OA symptoms, but factors not directly related to OA symptoms are also of importance. However, a large proportion of patients with OA do not seem to require surgery within five years, especially among those with knee OA. Cite this article: Bone Joint J 2022;104-B(7):792-800.

Debridement, antibiotics, and implant retention after revision arthroplasty : antibiotic mismatch, timing, and repeated DAIR associated with poor outcome

AIMS

Debridement, antibiotics, and implant retention (DAIR) is a widely accepted form of surgical treatment for patients with an early periprosthetic joint infection (PJI) after primary arthroplasty. The outcome of DAIR after revision arthroplasty, however, has not been reported. The aim of this study was to report the success rate of DAIR after revision arthroplasty with a follow-up of two years.

METHODS

This retrospective study, conducted at the Sint Maartenskliniek, Nijmegen, the Netherlands, included 88 patients who underwent DAIR within 90 days of revision total hip or total knee arthroplasty between 2012 and 2019. Details of the surgical procedures and PJI were collected. Univariate analysis and a subgroup analysis of the culture-positive group were performed. Kaplan-Meier survivorship curves were constructed.

RESULTS

The overall success rate of DAIR, with respect to the retention of components and the cure of infection, was 68% after two years. DAIR performed with an interval of > 30 days after the index revision procedure (odds ratio (OR) 0.24 (95% confidence interval (CI) 0.08 to 0.72); p = 0.008), a repeated DAIR within 90 days (OR 0.37 (95% CI 0.14 to 0.97); p = 0.040), and the use of an immunosuppressive agent (OR 0.13 (95% CI 0.02 to 0.67); p = 0.012) were associated with a significantly reduced success rate. In the culture-positive group, a mismatch between the antibiotic treatment and the susceptibility of the organism was associated with a significantly lower success rate (OR 0.13 (95% CI 0.03 to 0.62); p = 0.007).

CONCLUSION

DAIR is an acceptable form of surgical treatment for patients with a suspected early PJI after revision arthroplasty of the hip or knee. DAIRs performed after a prolonged interval, multiple DAIRs, and antibiotic mismatches were significantly associated with an increased risk of failure. Optimization of the host immune response and the prevention of antibiotic mismatch are modifiable factors that may improve the outcome. The high rate of mismatches was an important finding, underlining the need for a review of the local microbiological data, which might improve the outcome. Cite this article: Bone Joint J 2022;104-B(4):464-471.

Prior shoulder surgery and rheumatoid arthritis increase early risk of infection after primary reverse total shoulder arthroplasty

Background

Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular surgery for patients with rotator cuff arthropathy, unreconstructible proximal humeral fracture, and end-stage glenohumeral arthritis. The increased annual volume of RTSAs has resulted in more postoperative complications and revision rates between 3.3% and 10.1%. Postoperative infection is one of the most common complications requiring revision surgery after primary RTSA. This study assesses patient-specific risk factors for development of early infection after primary RTSA in a single high-volume shoulder arthroplasty institution.

Methods

From 2014 to 2019, 902 consecutive primary RTSAs were performed for surgical treatment of rotator cuff arthropathy, glenohumeral arthritis, inflammatory arthropathy, and/or dislocation. Excluding proximal humeral or scapula fractures, 756 cases met the inclusion criteria and had a minimum of 3-month follow-up. All surgeries were performed using the same surgical technique and received similar antibiotic prophylaxis. Age, patient demographics, medical history, smoking history, and prior ipsilateral shoulder treatment and/or surgery were recorded. Multivariable logistic regression analysis was used to determine risk factors associated with development of postoperative shoulder infection.

Results

Thirty-five patients did not meet minimum follow-up criteria and were lost to follow-up. Overall, of 721, 22 patients (3%) developed a postoperative ipsilateral shoulder infection. Previous nonarthroplasty surgery and history of rheumatoid arthritis were significantly associated with the development of postoperative shoulder infection. Amongst 196 patients who had previous nonarthroplasty shoulder surgery, there were 12 postoperative shoulder infections (6%) compared with those without previous shoulder surgery (10 of 525, 2%) (P = .003). Among 58 patients with rheumatoid arthritis, there were 5 postoperative shoulder infections (9%) compared with patients without rheumatoid arthritis (17 of 663, 3%) (P = .010). Patient age, gender, smoking status, history of diabetes mellitus, history of cancer/immunosuppression, and prior cortisone injection did not demonstrate significant associations with the development of postoperative infection.

Conclusion

Prior nonarthroplasty shoulder surgery and/or rheumatoid arthritis are independently associated with the development of postoperative infection after primary RTSA. Patients who demonstrate these risk factors should be appropriately evaluated and preoperatively counseled before undergoing primary RTSA. Strong consideration should be given to avoid minimally invasive nonarthroplasty surgery as a temporizing measure to delay definitive RTSA.

Implementation of an enhanced recovery protocol at a safety net hospital : a silver lining to COVID-19?

AIMS

This study aimed to evaluate whether an enhanced recovery protocol (ERP) for arthroplasty established during the COVID-19 pandemic at a safety net hospital can be associated with a decrease in hospital length of stay (LOS) and an increase in same-day discharges (SDDs) without increasing acute adverse events.

METHODS

A retrospective review of 124 consecutive primary arthroplasty procedures performed after resuming elective procedures on 11 May 2020 were compared to the previous 124 consecutive patients treated prior to 17 March 2020, at a single urban safety net hospital. Revision arthroplasty and patients with < 90-day follow-up were excluded. The primary outcome measures were hospital LOS and the number of SDDs. Secondary outcome measures included 90-day complications, 90-day readmissions, and 30day emergency department (ED) visits.

RESULTS

The mean LOS was significantly reduced from 2.02 days (SD 0.80) in the pre-COVID cohort to 1.03 days (SD 0.65) in the post-COVID cohort (p < 0.001). No patients in the pre-COVID group were discharged on the day of surgery compared to 60 patients (48.4%) in the post-COVID group (p < 0.001). There were no significant differences in 90-day complications (13.7% (n = 17) vs 9.7% (n = 12); p = 0.429), 30-day ED visits (1.6% (n = 2) vs 3.2% (n = 4); p = 0.683), or 90-day readmissions (2.4% (n = 3) vs 1.6% (n = 2); p = 1.000) between the pre-COVID and post-COVID groups, respectively.

CONCLUSION

Through use of an ERP, arthroplasty procedures were successfully resumed at a safety net hospital with a shorter LOS and increased SDDs without a difference in acute adverse events. The resulting increase in healthcare value therefore may be considered a 'silver lining' to the moratorium on elective arthroplasty during the COVID-19 pandemic. These improved efficiencies are expected to continue in post-pandemic era. Cite this article: Bone Jt Open 2021;2(10):871-878.

Mandatory Nicotine Cessation for Elective Orthopedic Hip Procedures Results in Reduction in Postoperative Nicotine Use

Purpose

To determine the efficacy of mandatory preoperative nicotine cessation on postoperative nicotine use, and to identify independent predictors of nicotine use relapse in subjects undergoing hip preservation surgery or total hip arthroplasty by a single fellowship-trained orthopedic surgeon.

Methods

Consecutive subjects that underwent hip surgery from November 2014 to December 2017 were reviewed. Subjects who self-reported nicotine use, quit prior to surgery, and completed a minimum one-year follow-up were included. Multiple linear regression models were constructed to determine the effect of independent variables on nicotine use relapse following surgery.

Results

Sixty subjects were included in the study (mean follow-up 35.1 months (17-57 months), mean age 44.9 years (20-82 years), and 23 (38.3%) males). Twenty-eight subjects (46.7%) remained nicotine-free at final follow-up. The mean number of cigarettes per day decreased from 13.4 preoperatively to 8.4 postoperatively in the subjects who relapsed (P=0.002). The mean time to return to nicotine postoperatively was 2.4 months. The number of preoperative cigarettes per day was the only independent predictor of tobacco use relapse (P=0.005).

Conclusion

Mandatory preoperative nicotine cessation prior to elective hip surgery demonstrates a 46.7% nicotine-free survivorship at final follow-up with the number of preoperative cigarettes per day found to be the only independent predictor of nicotine use relapse.

Level of evidence

The level of evidence of this research study is Level III since it is a non-experimental study with a cohort of patients.

Acute kidney injury following prophylactic flucloxacillin and gentamicin in primary hip and knee arthroplasty

Background

Following concerns regarding the emergence of Clostridium difficile infection in 2010, we changed antibiotic prophylaxis in patients undergoing primary hip and knee arthroplasty from cefuroxime to flucloxacillin and single-dose (SD) gentamicin. A subsequent perceived increase in the incidence of post-operative acute kidney injury (AKI) led us to evaluate the AKI incidence between different prophylactic antibiotic regimes used at our centre.

Methods

We examined the incidence of AKI as defined by Kidney Disease: Improving Global Outcomes criteria in 1588 patients undergoing primary hip or knee arthroplasty from January 2010 to January 2015. Patients received the following prophylactic antibiotic regimes: 8 g flucloxacillin in four divided doses and SD gentamicin 1.5 mg/kg ideal body weight (IBW; maximum dose 120 mg; n = 400), 8 g flucloxacillin alone in four divided doses (n = 400), SD cefuroxime (n = 400), triple-dose (TD) cefuroxime (n = 188) and teicoplanin with SD gentamicin 1.5 mg/kg IBW (n = 200).

Results

The incidence of AKI was as follows: flucloxacillin and gentamicin (13%); flucloxacillin alone (8.5%); SD cefuroxime (2%); TD cefuroxime (0.5%); and teicoplanin and gentamicin (3%). Of the six patients who developed Stage 3 AKI, all were in the flucloxacillin and gentamicin group. The odds ratio for the development of AKI derived from a binary logistic regression model was highest in the flucloxacillin and gentamicin group [7.79 (95% confidence interval 3.54–17.14), P < 0.0001].

Conclusions

Our findings suggest that the use of prophylactic high-dose flucloxacillin and gentamicin should be used with caution in patients undergoing primary hip or knee arthroplasty without a clear advantage in reducing surgical site infections given the association with increased rates of AKI.

Three-year results of a polycarbonate urethane acetabular bearing in total hip arthroplasty

BACKGROUND

Polycarbonate urethane (PCU) is a bearing surface with a lower modulus of elasticity than polyethylene or ceramic and is thought to more closely replicate the tribology of native hyaline cartilage. The purpose of this study was to determine the clinical outcomes with the use of PCU in elective total hip arthroplasty (THA).

METHODS

We carried out a prospective observational study in which 157 patients underwent elective THA with a metal-on-PCU hip system. Patients had radiographic follow-up at 6 months and 3 years after surgery. Oxford Hip Scores and EuroQol scores were obtained annually and Harris Hip Scores were obtained at 6 months and 3 years after surgery.

RESULTS

180 hips were implanted, of which, 149 hips reached 3-year review with no revisions. There was an increase in Harris Hip Scores, Oxford Hip Scores and EuroQol scores (p < 0.001). 12 patients (12 hips) reported painless hip squeaking. There were no dislocations and no other adverse events were reported.

CONCLUSION

Our results showed satisfactory survivorship and improvements in patient reported outcomes with metal on PCU THA. Long-term data are still being collected to confirm these findings. We recommend further tribological research into the squeaking phenomenon we observed.

Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Primary Hip and Knee Arthroplasty as Reported by American Board of Orthopedic Surgery Part II Candidates

BACKGROUND

Many strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies.

METHODS

The American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used.

RESULTS

In total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients.

CONCLUSION

It was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis.

LEVEL OF EVIDENCE

Therapeutic Level III.

DISCLAIMER

All views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.

Cutaneous Hypesthesia and Kneeling Ability After Total Knee Arthroplasty: A Randomized Controlled Trial Comparing Anterolateral and Anteromedial Skin Incision

BACKGROUND

Anterolateral skin incision can preserve the skin sensory of the anterior aspect of the knee and may improve kneeling ability after total knee arthroplasty (TKA).

METHODS

This is a prospective, 2-arm, parallel-group, randomized, controlled trial involving patients scheduled for TKA. A total of 118 patients (162 knees) were randomly assigned to receive anterolateral skin incision or anteromedial skin incision with 1:1 treatment allocation. The surgical techniques other than skin incision were identical in both groups. The area of cutaneous hypesthesia was measured by a nonblinded assessor, and kneeling ability was evaluated by 2 blinded assessors at 12 months after surgery.

RESULTS

The area of cutaneous hypesthesia was significantly smaller in the anterolateral skin incision group than the anteromedial skin incision group (3.0 ± 8.7 cm² vs 10.6 ± 18.6 cm²; 95% confidence interval, 2.8-12.3 cm²; P = .0019). The rates of patients judged to be able to kneel were significantly higher in the anterolateral skin incision group by both assessors (81% vs 60%; P = .025 and 81% vs 59%; P = .015, respectively) with almost perfect agreement between the 2 assessors (kappa value = 0.94). There were no significant differences in terms of complication rate, including wound complications, between the 2 groups (P > .05).

CONCLUSION

Compared with anteromedial skin incision, anterolateral skin incision may provide less cutaneous hypesthesia and better kneeling ability after TKA without increasing complication rate.

A Pilot Study of Augmented Reality Technology Applied to the Acetabular Cup Placement During Total Hip Arthroplasty

BACKGROUND

We developed an acetabular cup placement device, the AR-HIP system, using augmented reality (AR). The AR-HIP system allows the surgeon to view an acetabular cup image superimposed in the surgical field through a smartphone. The smartphone also shows the placement angle of the acetabular cup. This preliminary study was performed to assess the accuracy of the AR-HIP system for acetabular cup placement during total hip arthroplasty (THA).

METHODS

We prospectively measured the placement angles using both a goniometer and AR-HIP system in 56 hips of 54 patients undergoing primary THA. We randomly determined the order of intraoperative measurement using the 2 devices. At 3 months after THA, the placement angle of the acetabular cup was measured on computed tomography images. The primary outcome was the absolute value of the difference between intraoperative and postoperative computed tomography measurements.

RESULTS

The measurement angle using AR-HIP was significantly more accurate in terms of radiographic anteversion than that using a goniometer (2.7° vs 6.8°, respectively; mean difference 4.1°; 95% confidence interval, 3.0-5.2; P < .0001). There was no statistically significant difference in terms of radiographic inclination (2.1° vs 2.6°; mean difference 0.5°; 95% confidence interval, -1.1 to 0.1; P = .13).

CONCLUSION

In this pilot study, the AR-HIP system provided more accurate information regarding acetabular cup placement angle than the conventional method. Further studies are required to confirm the utility of the AR-HIP system as a navigation tool.

Hospital Discharge Within 1 Day After Total Joint Arthroplasty From a Veterans Affairs Hospital Does Not Increase Complication and Readmission Rates

BACKGROUND

Attempts to control costs associated with total joint arthroplasty have included efforts to shorten hospital length of stay (LOS). Concerns related to patient outcomes and safety with decreased LOS persist. The purpose of this study was to investigate whether discharge on postoperative day (POD) 1 after joint replacement is associated with increased rates of 90-day return to the operating room, and 30-day readmissions and emergency department (ED) visits.

METHODS

After chart review, 447 patients admitted between January 2, 2013 and September 16, 2016 met inclusion criteria. All patients underwent one total joint arthroplasty. Patients were either discharged on POD 1 (subgroup 1) or POD 2 or 3 (subgroup 2). Statistical evaluation was performed using Wilcoxon-Mann-Whitney tests for continuous variables, and Fisher exact tests for categorical and frequency data. Statistical significance was established at P ≤ .05.

RESULTS

Subgroup 1 had significantly fewer return trips to the operating room (P = .043) and significantly fewer 30-day readmissions (P = .033). ED visits were not significantly different between groups (P = .901).

CONCLUSION

Early discharge after joint arthroplasty appears to be a viable practice and did not result in increased rates of reoperation within the 90-day global period, or rates of 30-day readmission and ED visits. Our results support the utilization of an early discharge protocol on POD 1, with no evidence that shorter LOS results in higher rates of short-term complications.

The Effects of Body Mass Index on Pain Control With Liposomal Bupivacaine in Hip and Knee Arthroplasty

BACKGROUND

There is evidence to suggest that liposomal bupivacaine (LB) is an effective component of a multimodal pain regimen for total joint arthroplasty (TJA). Obesity has been associated with chronic pain following TJA. This study assessed whether early postoperative pain is affected by body mass index (BMI), and whether the standard LB dose has similar effects on obese vs nonobese patients.

METHODS

A retrospective analysis of 2629 primary TJA over a 12-month period was conducted, with LB used in half of this group. Patients were further classified as nonobese (BMI < 30) or obese (BMI ≥ 30). Pain scores and narcotic use were recorded. Independent-sample t-tests were used for continuous variables and chi-squared analyses for categorical variables. A multivariate regression analysis was performed.

RESULTS

Significantly less narcotic was required on postoperative days (POD) 0 and 1 in patients receiving LB compared to those who did not in both obese and nonobese patient groups. On POD 2, obese and nonobese patients had an increase in narcotic requirement, which was significant in obese patients. A regression analysis found that on POD 0 and POD 1, lack of LB use, obesity, and younger age were independently associated with increased narcotic use.

CONCLUSION

While narcotic requirement of obese and nonobese patients decreased on POD 0 and POD 1 with initiation of LB at our institution, all patients demonstrated increased narcotic requirement on POD 2 which was statistically and clinically significant in obese patients. Further studies are needed to determine the optimal pain regimen in the growing obese population undergoing TJA.

Intravenous Acetaminophen in Multimodal Pain Management for Patients Undergoing Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Although multimodal pain management including periarticular multidrug injection can provide excellent pain relief in the early postoperative period after total knee arthroplasty (TKA), rebounding pain remains an important challenge. A randomized, double-blind, placebo-controlled trial was performed to investigate the efficacy of adding intravenous acetaminophen to multimodal pain management for TKA.

METHODS

We enrolled 67 patients scheduled for unilateral TKA. Patients were randomly assigned to receive either 1000 mg of intravenous acetaminophen at 6-hour intervals or normal saline at the same intervals. All patients were treated with intraoperative periarticular multidrug injection and intravenous and oral nonsteroidal anti-inflammatory drugs. The primary outcome was the postoperative 100-mm visual analog pain scale at the time of administration of study drugs.

RESULTS

In the intention-to-treat analysis, the pain score was significantly better in the intravenous acetaminophen group than the placebo group at 17:00 one day after TKA (15.3 ± 17.0 mm vs 26.8 ± 19.0 mm; P = .013). There were no significant differences in terms of the rate of complications between groups.

CONCLUSION

Even in the setting of multimodal pain management including periarticular multidrug injection, intravenous acetaminophen provided better pain relief for patients undergoing unilateral TKA.

Impact of Soft Tissue Imbalance on Knee Flexion Angle After Posterior Stabilized Total Knee Arthroplasty

BACKGROUND

This study was performed to assess the impact of soft tissue imbalance on the knee flexion angle 2 years after posterior stabilized total knee arthroplasty (TKA).

METHODS

A total of 329 consecutive varus knees were included to assess the association of knee flexion angle 2 years after TKA with preoperative, intraoperative, and postoperative variables. All intraoperative soft tissue measurements were performed by a single surgeon under spinal anesthesia in a standardized manner including the subvastus approach, reduced patella, and without use of a pneumonic tourniquet.

RESULTS

Multiple linear regression analysis showed no significant correlations in terms of intraoperative valgus imbalance at 90-degree flexion or the difference in soft tissue tension between 90-degree flexion and 0-degree extension (β = -0.039; 95% confidence interval [CI], -0.88 to 0.80; P = .93 and β = 0.015; 95% CI, -0.29 to 0.32; P = .92, respectively). Preoperative flexion angle was significantly correlated with knee flexion angle 2 years after TKA (β = 0.42; 95% CI, 0.33 to 0.51; P < .0001).

CONCLUSION

Avoiding valgus imbalance at 90-degree flexion and aiming for strictly equal soft tissue tension between 90-degree flexion and 0-degree extension had little practical value with regard to knee flexion angle 2 years after posterior stabilized TKA.

Reverse shoulder arthroplasty in patients younger than 55 years: 2- to 12-year follow-up

BACKGROUND

This study reports the outcomes of reverse shoulder arthroplasty (RSA) in patients younger than 55 years with midterm to long-term follow-up.

METHODS

Sixty-seven patients (average age, 47.9 years; range, 21-54 years) were identified who underwent RSA with an average 62.3 months of follow-up (24-144 months). There were 35 patients (group 1) who had a failed arthroplasty and 32 patients (group 2) who underwent primary RSA. Clinical outcomes included the American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, and range of motion. Complications included radiographic failures (fracture, dislocation, notching, loosening), infections, and nerve palsies.

RESULTS

Group 1 showed significant improvements in flexion and abduction but not in external or internal rotation. Group 2 showed significant improvements in flexion, abduction, and internal rotation but not in external rotation. Both groups showed significant improvements in ASES and SST scores. In group 1, ASES score improved from 24.4 to 40.8 (P = .003), and SST score improved from 1.3 to 3.2 (P = .043). In group 2, ASES score improved from 28.1 to 58.6 (P < .001), and SST score improved from 1.3 to 4.5 (P = .004). The total complication rate was 22.4%. The total reoperation rate was 13.4%, and the revision rate was 8.9%. The implant retention rate was 91% at last follow-up.

CONCLUSION

RSA in patients younger than 55 years provides significant clinical improvements with high implant retention at up to 12 years. Patients undergoing revision RSA begin with worse function than those undergoing primary RSA, but they can expect similar degrees of improvement. Complications were higher but reoperation rates were lower in the revision group. No mechanical failures occurred in the primary group, with infection the cause of all revisions.

Incidence of Adverse Reactions to Metal Debris From 28-mm Metal-on-Metal Total Hip Arthroplasties With Minimum 10 Years of Follow-Up: Clinical, Laboratory, and Ultrasound Assessment of 44 Cases

BACKGROUND

Total hip arthroplasty with metal-on-metal (MoM) bearings has been suspected to cause adverse reactions to metal debris (ARMD), with the incidence varying greatly by implant type and patient gender. The prevalence of ARMD from small-diameter MoM bearings in women is unknown, especially after 10 years of follow-up (FU).

METHODS

Cementless 28-mm MoM total hip arthroplasty bearings (Metasul) were implanted consecutively in 42 active women between 1996 and 2002. They were reviewed after a minimum of 10 years' FU with clinical, laboratory, radiological, and ultrasound assessments.

RESULTS

Mean FU was 15.9 years (range, 13-18). The mean Postel-Merle d'Aubigné and Oxford scores were 16.9 (range, 13-18) and 15.1 (range, 12-24), respectively, at FU. Mean cup inclination angle was 46.3° (range, 35°-57°). No femoral osteolysis was detected, but limited acetabular osteolysis (11%) over the screw holes occurred in 5 cases. No liquid or solid synovial reactions or ARMD were apparent on ultrasound, even in the 5 cases of pelvic osteolysis. Mean chromium levels were 1.32 μg/L (range, 0.1-7.9) and cobalt levels were 1.85 μg/L (range, 0.35-13.6). Cobalt was >3 μg/L in only 3 cases. The 15.9-year survivorship was 95% (range, 94.1%-98.9%).

CONCLUSION

Reliable results were obtained with 28-mm MoM bearings, notably in young, active patients. This implant configuration requires very accurate positioning. No ARMD was seen in this group at 16 years' FU.

Complications of locked plating for proximal humeral fractures-are we getting any better?

BACKGROUND

Complication rates reported after locking plate fixation of proximal humeral fractures still range up to 40%. Whether modifications of surgical techniques, use of primary shoulder arthroplasty, or a fracture-specific management resulted in decreased complication rates during recent years remains unclear. Therefore, the aim of this long-term observation study was to analyze the incidence of complications and revision surgery after locked plating.

METHODS

Between February 2002 and December 2013, 788 patients (aged 67.4 ± 17.3 years) with displaced proximal humeral fractures were treated with locking plate, primary hemiarthroplasty (HA), or reverse shoulder arthroplasty (RSA). Standardized follow-up included radiographs at 1 day, 6 weeks, and 3, 6, and 12 months. Complications and unplanned revision surgery were prospectively recorded over the complete follow-up.

RESULTS

Of 788 patients, 646 (82%) were treated with locking plate, 82 (10.4%) with HA, and 60 (7.6%) with RSA. Mean follow-up was 14.8 ± 3.8 months. The mean complication rate associated with locked plating was 12.8%, and revision surgery was necessary in 11.6%. Within the last 5 years, the loss of fixation rate markedly decreased from 14.3% to 4.8%; simultaneously, an increased use of RSA was observed.

CONCLUSION

The overall complication rate of locking plate osteosynthesis for proximal humeral fractures has been decreasing considerably within the last years. Among others, this might be due to an increased use of primary RSA for complex fracture types. In addition to a precise surgical technique, choosing the adequate treatment for each individual fracture to avoid complications and revision surgery is of utmost importance.

One-stage total knee arthroplasty with pre-existing fracture deformity: post-fracture total knee arthroplasty

The aim of the study was to assess the results of treating knee osteoarthrosis with total knee arthroplasty (TKA) after previous tibia and/or femur fractures resulting in axial limb deformities. Thirty-six knees (34 patients) were operated on. At the most recent follow-up, 4.8 years after surgery, all but one patient demonstrated an improvement in both clinical and functional KSS. This male patient required revision after 2 years. Improved range of motion was generally noted, especially extension, however, two patients with both tibia and femur fractures had worse results. TKA is an effective method of treatment for patients with arthrosis after a previous femur or tibia fractures. When deformity is severe semi-constrained or constrained, implants with extensions may be necessary.

Cost benefit analysis of topical tranexamic acid in primary total hip and knee arthroplasty

The purpose of this study was to provide a cost-benefit analysis of topical tranexamic acid (TXA) in primary total hip and knee arthroplasty patients. A retrospective cohort of 591 consecutive patients, 311 experimental and 280 control, revealed a transfusion rate reduction from 17.5% to 5.5%, increased postoperative hemoglobin, and decreased delta hemoglobin without an increase in adverse events (all P < 0.001). This led to saving $83.73 per patient based on transfusion costs alone after accounting for the cost of TXA. Hospital disposition to home compared to subacute nursing facility was also significantly increased by 9.3% (P < 0.02). We conclude that topical TXA reduces transfusion rate, increases home disposition, and reduces cost in primary hip and knee arthroplasty.

Primary rotating-hinge total knee arthroplasty: good outcomes at mid-term follow-up

We evaluated the clinical and radiologic outcomes of primary knee replacements using a rotating-hinge knee prosthesis in 12 knees with a minimum follow-up of 10 years. Indications for the operation included gross joint destruction, significant axial deformities and contracture with a dysfunctional medial collateral ligament in all cases. The patients' WOMAC and Knee Society scores improved, and the use of mobility aids decreased. No loosening of implants was observed. Nonprogressive radiolucent lines were identified around three tibial components. Three patients required marginal wound excision with resuturing and thereafter healed uneventfully. With significant improvement in function, pain and range of motion, the rotating-hinge knee prosthesis can be used as a salvage device in patients with medial collateral ligament deficiency, contracture, and gross joint destruction.