Reduced Incidence of Perioperative Periprosthetic Fractures Using Hybrid Rasp-Impaction Broaching Over Impaction Broaching When Using the Direct Anterior Approach for Total Hip Arthroplasty.

Background: A not infrequent complication encountered with the direct anterior approach is perioperative fracture. The purpose of this study was to compare the incidence of perioperative fractures using a hybrid rasp-impaction broach vs an impaction broach for a similarly designed stem. Methods: Retrospective study of 798 primary total hip replacements by 1 surgeon performed using noncollared dual tapered femoral stems, including 457 implanted using hybrid rasp-impaction broaching and 341 implanted using impaction broaching. Intraoperative and 90-day postoperative fractures were identified in each group. Bivariate tests and multivariate regression analysis were used to compare the 2 groups. Results: There were 33 (4.1%) fractures in the sample, 13 (2.8%) with hybrid rasp-impaction broaching and 20 (5.8%) with impaction broaching (P = .034). Three (0.7%) intraoperative fractures occurred with hybrid rasp-impaction broaching and 12 (3.5%) with impaction broaching (P = .003). Five (1.1%) total calcar fractures occurred with hybrid rasp-impaction broaching and 11 (3.2%) with impaction broaching (P = .034). Intraoperative calcar fractures occurred with 1 (0.2%) hybrid rasp-impaction broaching and 6 (1.8%) impaction broaching (P = .021). In multivariate analyses, hybrid rasp-impaction broaching had a statistically lower odds ratio (OR) for total fracture (OR 0.45 [0.22 to 0.93]); total intraoperative fracture (OR 0.17 [0.05 to 0.60]); total calcar fracture (OR 0.33 [0.11 to 0.97]); intraoperative calcar fracture (OR 0.11 [0.01 to 0.98]); and rate of readmission (OR 0.27 [0.10 to 0.78]). Conclusion: The use of a hybrid rasp-impaction broach compared with impaction broach led to a reduced incidence of periprosthetic fractures when using a dual tapered stem through the direct anterior approach.

Perioperative Complications Stratified by Body Mass Index for the Direct Anterior Approach to Total Hip Arthroplasty.

BACKGROUND: Previous studies have addressed the increased risk of perioperative complications in the obese and morbidly obese populations undergoing total hip arthroplasty. Over the last 15 years, the direct anterior approach has increased in popularity. The purpose of this study is to compare the 90-day perioperative complication rate of total hip arthroplasty performed through the direct anterior approach stratified by body mass index (BMI). METHODS: Perioperative complications both intraoperative and up to 90 days postoperative were identified in a case series of 1808 primary total hip arthroplasties performed through a direct anterior approach. The patients were stratified according to BMI. Demographics of age, side, sex, and American Society of Anesthesiologists score were recorded. Medical and surgical complications including National Surgical Quality Improvement Program complications, length of stay, reoperation rate, readmission rate, and length of operation were recorded. Bivariate analysis and analysis of variance were performed. RESULTS: Morbidly obese patients (BMI > 40) demonstrated increased American Society of Anesthesiologists scores, increased surgical times with statistically significant increase in number of patients with surgical complications, National Surgical Quality Improvement Program complications, deep infection, and wound breakdown. Grading the severity of complications also demonstrated the morbidly obese had a higher risk of experiencing more severe complications. Underweight patients (BMI < 18.5) demonstrated a statistically significant readmission rate. CONCLUSION: In stratifying patients undergoing the direct anterior approach for total hip arthroplasty by BMI, a greater rate of surgical complications both in number and in severity occurs with the morbidly obese undergoing total hip arthroplasty through a direct anterior approach.

Isolated Greater Trochanteric Fracture and the Direct Anterior Approach Using a Fracture Table.

BACKGROUND: To identify the incidence, contributing factors, and outcomes of perioperative greater trochanter fractures associated with the direct anterior approach. METHODS: This is a retrospective analyses of 1401 primary THAs. Age, side, height, weight, body mass index, preoperative ambulatory status, discharge status, and hospital length of stay were identified. Radiographs were evaluated for femoral neck angle, femoral neck cut ratio (FNCR), and DORR ratio. Bivariate and logistic regression analyses were performed. RESULTS: Thirty-one hips sustained isolated greater trochanter fractures (2.2%). Multivariate analyses identified worse preoperative ambulatory status, diagnosis of slipped capital femoral epiphysis or rheumatoid arthritis, lower FNCR and greater DORR ratio as statistically significant predictors for fracture. Four intraoperative fractures underwent fixation. All postoperative fractures were treated nonoperatively. Thirty fractures healed with 1 nonunion. CONCLUSION: Worse preoperative ambulatory status, diagnosis of slipped capital femoral epiphysis or rheumatoid arthritis, greater DORR ratio, and lower FNCR were associated with increased risk of fracture. Hips with fractures had longer length of stay. Nonoperative treatment was uniformly successful.

MI TKA: a risk factor for early revision surgery.

Minimal incision total knee arthroplasty (MI TKA) was developed with the potential to decrease surgical trauma, pain, and recovery time. While this procedure has increased in popularity, some surgeons have questioned its safety and long-term efficacy. In this study 58 consecutive revision total knee arthroplasties (TKAs) (57 patients) performed at one academic medical center from 2006 to 2008 are reviewed. Prospectively collected clinical and radiographic data included: incision length, gender, age, time to revision surgery, and primary diagnosis at time of revision. Of these, 34 knees involving infection and rerevision were excluded. Of the remaining 24 knees, 11 knees that met inclusion criteria had undergone MI TKA. There were no differences between the groups with regard to age, diagnosis, body mass index, and gender. Average time to revision was shorter for the MI TKA patients (29 vs. 65 months, p < 0.032, odds ratio 14.7). Reasons for revision were aseptic loosening (55%), pain/stiffness (27%), malrotation (9%), and instability (9%) in the MI TKA group and aseptic loosening (53%), instability (15%), pain/stiffness (8%), malrotation (8%), combined malrotation and instability (8%), and polyethylene wear/osteolysis (8%) in the traditional TKA group. These data suggest that MI TKA may be a risk factor for early revision.

Rotational references for total knee arthroplasty tibial components change with level of resection.

BACKGROUND: Various landmarks can guide tibial component rotational alignment in routine TKA, but with the deeper tibial resection levels common in complex primary and revision TKAs, it is unknown whether these landmarks remain reliable. QUESTIONS/PURPOSES: We asked whether three techniques for determining tibial component rotation based on local anatomic landmarks are reliable deeper tibial resection levels. PATIENTS AND METHODS: The femoral transepicondylar axis was identified by three independent reviewers on MR images of knees from 24 men and 24 women and transposed at a traditional tibial resection level and at the level of the proximal, middle, and distal parts of the proximal tibiofibular joint. Three axes were drawn on axial slices at these levels: the geometric center of the tibial plateau to the medial 1/3 of the tubercle, the posterior condylar line of the tibia, and the largest mediolateral dimension of the tibia. These lines were compared with the transposed femoral epicondylar axis line. RESULTS: The posterior condylar line of the tibia is the least variable local landmark for tibial component positioning at deep resection levels. CONCLUSIONS: Assuming the normal posterior condylar line of the tibia is visible at revision, setting the tibial component at 10° external rotation with respect to the posterior condylar axis of the tibia gets the tibial component within 10° of proper rotation in 86% to 98% of patients, even to the distal part of the proximal tibiofibular joint. The experienced surgeon then can adjust this position based on cues from an assortment of other axes.

Minimal incision surgery as a risk factor for early failure of total hip arthroplasty.

BACKGROUND: Minimal incision total hip arthroplasty (MI THA) techniques were developed to decrease postoperative pain and recovery time. Although these techniques have increased in popularity, the long-term survivorship of these procedures is unknown. QUESTIONS/PURPOSES: We therefore investigated whether the time to revision in our referral practice was shorter for patients who underwent primary MI THA compared to primary traditional THA. METHODS: We retrospectively reviewed 46 revision THAs performed during a 3-year period. We excluded revisions performed for infection and rerevisions. Patients with incisions less than or equal to 10 cm were defined as having had MI THA. Fifteen of the 46 patients (33%) had undergone primary MI THA. At the time of primary index THA, the mean ages of the MI and non-MI patients were 65 years and 55 years, respectively. RESULTS: The mean time to revision was 1.4 years for the MI patients compared with 14.7 years for the non-MI patients. Twelve of the 15 patients having MI THA required revision within 2 years of primary THA compared to 4 of the 31 patients without MI surgery (OR = 26.5, 95% CI 4.4-160.0). There were no differences between the groups with regard to age, gender, or body mass index. The most common reasons for revision in the MI THA group were intraoperative fracture and failure of femoral component osseointegration. CONCLUSIONS: Our data suggest MI THA may be a risk factor for early revision surgery and the long-term survival therefore may be lower than that for non-MI surgery. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Bilateral knee arthrodesis in a patient with common variable immunodeficiency.

Patients with common variable immunodeficiency can present with debilitating arthritis. We present the case of a 42-year-old man with bilateral knee arthritis who underwent a right total knee arthroplasty that subsequently became infected. Five months after resection arthroplasty, his right leg spontaneously fused in extension, but his left knee was limited to an arc of motion between 90° and 110°. At the patient's request, he underwent a noninstrumented arthrodesis of the left knee. The patient now has bilateral arthrodeses and ambulates with a cane. While arthroplasty may be attempted in such patients, the increased risk of infection may potentially result in arthrodesis, possibly without instrumentation.

Low back pain in the aging athlete.

Low back pain has an incidence between 1% and 30% in athletes. The natural history of low back pain is such that greater than 90% will improve without medical attention. Our treatment algorithm begins by ruling out nonspinal related causes of low back pain including neoplasm, infection, and serious medical conditions. Next cauda equina compression is differentiated from clinical entities that can be treated on an elective basis. Low back strain, herniated nucleus pulposis, spinal stenosis, and degenerative disease are each discussed with an emphasis on imaging studies finding a correlation between history, physical, and the neurodiagnostic testing. Athletes over the age of 60 who require back surgery should understand that they would most likely not return to their previous level of activity. Recent work has focused on rehabilitative principles such as core stabilization and their role in the prevention and treatment of athletes with lumbar disorders.