The anterior approach for conversion hip arthroplasty.

Conversion of prior proximal femoral fracture fixation to hip arthroplasty is a fairly common and successful procedure, necessitated by various modes of failure. The procedure is well described utilizing a posterior or anterolateral surgical approach. The anterior approach for total hip arthroplasty has gained in popularity. The approach allows for supine positioning and facilitates live fluoroscopic imaging. We present possible advantages and disadvantages, as well as the surgical technique, of conversion to total hip arthroplasty via the direct anterior approach.

Ninety-day postoperative cost in primary total hip arthroplasty: an economic model comparing surgical approaches.

BACKGROUND: While primary total hip arthroplasty (THA) is a safe and effective procedure, it is unclear whether choice of surgical approach influences health care cost. METHODS: We developed an economic model in which patients receiving THA via the anterior approach (AA) by high volume anterior hip surgeons were compared to a propensity-score matched cohort of primary THA cases performed by high volume surgeons that were identified from Medicare claims (Control). Cost elements included the procedure and hospital stay, postacute care, readmission, and outpatient care through 90 days postoperatively. Costs were derived from Medicare claims and adjusted to account for nationwide payer mix. RESULTS: Health care costs over 90 days postoperative were $17,763 with AA and $23,969 with Control, a difference of $6,206 (95% CI: $5,210-$7,204) per patient. The cost savings with AA were mainly attributable to lower per-patient costs of the index hospitalization ($13,578 vs $16,017), postacute care ($3,123 vs $6,037), and hospital readmissions ($700 vs $1,584). CONCLUSION: The AA for primary THA was found to lower 90-day health care costs when compared to a matched sample of THA cases. These study findings may be used to inform hospitals and health care payers regarding the cost implications associated with selection of different surgical approaches to primary THA.

Influence of surgical approach on complication risk in primary total hip arthroplasty.

Background and purpose - Systematic comparisons of anterior approach (A) versus posterior approach (P) in primary total hip arthroplasty (THA) have largely focused on perioperative outcomes. In this systematic review with meta-analysis, we compared complication risk of A versus P in studies of primary THA with at least 1-year mean follow-up. Patients and methods - We performed a systematic review of prospective and retrospective studies with at least 1-year mean follow-up that reported complications of A and P primary THA. Complications included infection, dislocation, reoperation, thromboembolic event, heterotopic ossification, wound complication, fracture, and nerve injury. Random effects meta-analysis was used for all outcomes. Complication risk was reported as rate ratio (RR) to account for differential follow-up durations; values >1 indicated higher complication risk with A and values <1 indicated lower risk with A. Results - 19 studies were included; 15 single-center comparative studies with 6,620 patients (2,278 A; 4,342 P) and 4 multicenter registries with 157,687 patients (18,735 A; 138,952 P). Median follow-up was 16 (12-64) months) with A and 18 (12-110) months with P. Anterior approach was associated with lower rate of infection (RR =0.55, p = 0.002), dislocation (RR =0.65, p = 0.03), and reoperation (RR =0.84, p < 0.001). No statistically significant differences were observed in rate of thromboembolic event (RR =0.59, p = 0.5), heterotopic ossification (RR =0.63, p = 0.1), wound complication (RR =0.93, p = 0.8), or fracture (RR =1.0, p = 0.9). There was a higher rate of patient-reported nerve injury with A (RR =2.3, p = 0.01). Interpretation - Comparing A with P in primary THA, A was associated with lower risk of reoperation, dislocation, and infection, but higher risk of patient-reported nerve injury.

Does Surgical Approach Affect Outcomes in Total Hip Arthroplasty Through 90 Days of Follow-Up? A Systematic Review With Meta-Analysis.

BACKGROUND: The choice between anterior approach (AA) and posterior approach (PA) in primary total hip arthroplasty (THA) is controversial. Previous reviews have predominantly relied on data from retrospective studies. METHODS: This systematic review included prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA. Outcomes were pain severity, narcotic usage, hip function using Harris Hip Score, and complications. Random effects meta-analysis was performed for all outcomes. Efficacy data were reported as standardized mean difference (SMD) where values of 0.2, 0.5, 0.8, and 1.0 were defined as small, medium, large, and very large effect sizes, respectively. Complications were reported as the absolute risk difference (RD) where a positive value implied higher risk with AA and a lower value implied lower risk with AA. RESULTS: A total of 13 prospective comparative studies (7 randomized) with patients treated with AA (n = 524) or PA (n = 520) were included. The AA was associated with lower pain severity (SMD = -0.37, P < .001), lower narcotic usage (SMD = -0.36, P = .002), and improved hip function (SMD = 0.31, P = .002) compared to PA. No differences between surgical approaches were observed for dislocation (RD = 0.2%, P = .87), fracture (RD = 0.2%, P = .87), hematoma (RD = 0%, P = .99), infection (RD = 0.2%, P = .85), thromboembolic event (RD = -0.9%, P = .42), or reoperation (RD = 1.3%, P = .26). Conclusions of this study were unchanged when subjected to sensitivity analyses. CONCLUSION: In this systematic review and meta-analysis of prospective studies comparing postoperative outcomes through 90 days of AA vs PA in primary THA, patients treated with AA reported less pain, consumed fewer narcotics, and reported better hip function. No statistical differences in complication rates were detected between AA and PA. Ultimately, the choice of surgical approach in primary THA should consider preference and experience of the surgeon as well as preference and anatomy of the patient.

Simultaneous Bilateral Anterior Approach Total Hip Arthroplasty.

Simultaneous bilateral total hip arthroplasty (THA) has been performed successfully, with good outcomes and low complication rates reported. Most published studies on the topic used anterolateral or posterior surgical approaches. The anterior approach is performed under live fluoroscopy with the patient supine, obviating the need for patient repositioning during bilateral surgery. The authors report their experience with simultaneous bilateral anterior approach total hip arthroplasty. The authors retrospectively reviewed data for 75 patients (150 hips). Mean follow-up was 26 months (range, 5-60 months). Mean patient age was 59 years and the majority were American Society of Anesthesiology class 2 (range, 1-3). Mean total surgical time was 144 minutes (72 minutes per hip). Mean blood loss was 565 mL. Mean hospital length of stay was 2.75 days (range, 1-4 days). Ninety-six percent of patients were able to ambulate on postoperative day 1. Sixty-eight percent of patients were discharged to home. Mean Harris Hip Score improved from 50 to 97. All patients noted a return to preoperative level of activity or higher. Complications included 1 atraumatic minimally displaced trochanteric fracture occurring 2 weeks postoperatively, 1 pulmonary embolism on postoperative day 3 treated without sequelae, 1 episode of postoperative atrial fibrillation, and 4 minor local wound complications. No readmission, infection, nerve palsy, dislocation, reoperation, or death occurred. Anterior approach THA has the advantage of a single supine position for bilateral simultaneous surgery and the current study supports its use in appropriate patients.

Use of stepped porous titanium metaphyseal sleeves for tibial defects in revision total knee arthroplasty: short term results.

Stepped porous titanium metaphyseal sleeves may provide an option for enhanced fixation in managing challenging tibial defects in revision total knee arthroplasty (TKA). We retrospectively reviewed data on 51 patients who underwent revision TKA utilizing a metaphyseal sleeve for Anderson Orthopaedic Research Institute (AORI) Type II and III tibial defects between June 2007 and July 2011. Of these 51 patients, 36 patients had complete clinical and radiographic data. At final follow-up (mean: 38 months) significant improvements in knee range of motion and Knee Society scores were observed postoperatively (P < 0.001). Four revision procedures were necessary, but none for aseptic implant fixation failure. Radiographic review at final follow-up revealed stable, osteointegrated components without component migration or clinically significant osteolysis. Metaphyseal sleeve use in the management of moderate to severe tibial defects in revision TKA resulted in satisfactory clinical outcomes and is a versatile option for achieving stable fixation.

Day of surgery discharge after unicompartmental knee arthroplasty: an effective perioperative pathway.

Day of surgery (DOS) discharge after unicompartmental knee arthroplasty (UKA) allows for safe, efficient care of the appropriately selected patient. Refinement of our perioperative pathway over the last decade has allowed for successful DOS discharge of 160 consecutive patients. The cohort averaged 65 years and American Society of Anesthesiology class was 1-3 (mean, 1.8). Perioperative pain control included a preoperative single shot femoral nerve block. Mean recovery room time was 121 (SD = 37) minutes. No patient required overnight admission for uncontrolled pain or nausea. Significant improvements in Knee Society Clinical Rating System (KSCRS) scores and high patient satisfaction were observed. This study details critical components of our simple perioperative pathway that can be utilized to safely perform UKA with discharge on the DOS.

Biomechanical comparison of locking versus nonlocking volar and dorsal T-plates for fixation of dorsally comminuted distal radius fractures.

OBJECTIVES: The purpose of this study was to gain insight into the effect of plate location and screw type for fixation of extra-articular distal radius fractures with dorsal comminution (Orthopaedic Trauma Association Type 23-A3.2). METHODS: Sixteen pairs of cadaver radii were randomized to four plating configurations: dorsal locking, dorsal nonlocking, volar locking, and volar nonlocking. A standard 1-cm dorsal wedge osteotomy was used. Cyclic axial loads were applied for 5000 cycles. Stiffness and fragment displacement were recorded at 500 cycle-intervals. Pre- and postcyclic loading radiographs were analyzed. An axial load to failure test followed and construct stiffness and failure strength recorded. Biomechanical data were analyzed using a two-way analysis of variance (P < 0.05). Failure modes were descriptively interpreted. RESULTS: Cyclic testing data revealed no difference between constructs at any interval. Within all construct groups, displacement that occurred did so within the first 500 cycles of testing. Pre- and postcyclic loading radiographic analysis showed no differences in construct deformation. Load to failure testing revealed no differences between groups, whereas volar constructs approached significance (P = 0.08) for increased failure strength. Dorsal constructs failed primarily by fragment subsidence and fragmentation, whereas volar constructs failed by plate bending. CONCLUSIONS: No difference in all measured biomechanical parameters supports equivalence between constructs and surgeon discretion in determining operative method. Minimal fragment displacement and construct deformation during physiological testing support previous data that early postoperative motion can be recommended. Fragment displacement that occurs does so in the early periods of motion.

Salmonella osteomyelitis in new-onset diabetes mellitus.

Salmonella species are rare bacterial isolates in osteomyelitis. This article describes a case of an otherwise healthy, active duty male military member with an insidious onset of right knee pain during a deployment to Kuwait. His work-up revealed an infectious process in the distal femur. Operative treatment and intravenous antibiotics resolved the infection. Intraoperative cultures revealed the rare isolate Salmonella enterica serotype C2 (Newport). Postoperative medical management revealed new-onset diabetes mellitus, possibly making this otherwise healthy host susceptible to this rare infection. Salmonella are gram-negative bacteria. Infection with nontyphoidal Salmonella species most commonly manifests as intestinal illness. Although it may be difficult for clinicians to accurately predict this rare entity as the causative organism in osteomyelitis, they may be aided by a history of travel to endemic regions or exposure to animal carriers. Comorbidities that seem to increase susceptibility include diabetes mellitus, human immunodeficiency virus, hemoglobinopathies, and immunosuppression. Blood cultures are reported to be frequently positive in cases of Salmonella osteomyelitis. Identification of Salmonella species from intraoperative cultures should prompt consultation with the infectious disease department for culture-specific antibiotic tailoring. Many common antibiotic agents active against gram-negative organisms seem efficacious. As in this case, following the basic tenets of osteomyelitis management should lead to an acceptable outcome.

Protecting military convoys in Iraq: an examination of battle injuries sustained by a mechanized battalion during Operation Iraqi Freedom II.

Improvised explosive devices and mines pose a formidable threat to military convoys traveling in Iraq. This study evaluated battle injuries sustained by a mechanized battalion operating against this threat. The objective was to gain insight into injury profiles and prevention. In the period examined, 32 attacks injured 120 Marines, causing 188 injuries. Upper extremity and head injuries (70%) were common, whereas lower extremity injuries (11%) were rare (as expected, given the threat and the body areas exposed). Shoulder and axilla protectors may be beneficial, but lower arm and hand injuries remain difficult to combat. Ear injury was the most common single injury type (23%). Combat earplugs may reduce ear blast injuries. Eye injuries were uncommon (0.5%), likely because of ballistic eye protection. Injury to the torso (11%) was generally mild, because of body armor vests. The majority of wounds were minor, allowing > 80% of the injured Marines to return to duty.