Recurrent cyclops lesion after primary anterior cruciate ligament reconstruction using bone tendon bone allograft: A case report.

BACKGROUND: Cyclops lesions are a known complication of anterior cruciate ligament (ACL) reconstruction, with symptomatic cyclops syndrome occurring in up to 11% of surgeries. Recurrent cyclops lesions have been rarely documented; this case study documents the successful treatment of a recurrent cyclops lesion. CASE SUMMARY: A 28-year-old female presented following a non-contact injury to the right knee. Workup and clinical exam revealed an ACL tear, and arthroscopic reconstruction was performed. Two years later a cyclops lesion was discovered and removed via arthroscopic synovectomy. Seven months postoperatively, the patient presented with pain, stiffness, and difficulty achieving terminal extension. A smaller recurrent cyclops lesion was diagnosed, and a repeat synovectomy was performed. The patient recovered fully. CONCLUSION: To the best of our knowledge, this is the first documented case of recurrent cyclops lesion after bone-patellar tendon-bone allograft ACL reconstruction presenting as cyclops syndrome.

Chronic Dislocation of the Thumb Carpometacarpal Joint: A Case Report.

Dislocation of the thumb carpometacarpal (CMC) joint is a rare injury; chronic CMC dislocation can lead to significant disability. Traditionally, surgical intervention has focused on the reconstruction of the anterior oblique ligament, though more recently there has been more focus on the dorsoradial ligament. Consideration of both ligaments during CMC joint reconstruction is important to optimize functional outcomes. A 59-year-old male presented with a subacute/chronically dislocated CMC joint of the thumb. Open reduction with pin fixation and dorsoradial ligament repair and augmentation was chosen to restore the stability of the joint. Joint reduction without subluxation was successfully maintained. By 12 weeks postoperatively, there were no remaining major restrictions to activity. Repair of the dorsoradial ligament with augmentation and pinning is a viable approach for surgical management of subacute/chronic dislocation of the thumb CMC joint.

Tear of Quadriceps and Patellar Tendon with Superior Pole Avulsion of Patella: A Case Report.

CASE: A 58-year-old man presented with right knee pain and inability to extend the knee after falling. magnetic resonance imaging (MRI) demonstrated complete rupture of the quadriceps tendon, avulsion of the superior pole patella, and a high-grade partial tear of the proximal patellar tendon. Surgical dissection revealed that both tendon tears were full-thickness disruptions. Repair was performed without complications. The patient achieved independent ambulation and passive range of motion from 0° to 118° at 3.8 years postoperatively. CONCLUSIONS: We present a case of a simultaneous ipsilateral tear of the quadriceps and patellar tendons with superior pole patella avulsion that resulted in a clinically successful repair.

Acetabular Total Hip Arthroplasty Revision: A Summary of Operative Factors, Outcomes, and Comparison of Approaches.

BACKGROUND: Revision total hip arthroplasty (THA) presents a greater risk to patients than primary THA, and surgical approach may impact outcomes. This study aimed to summarize acetabular revisions at our institution and to compare outcomes between direct anterior and posterior revision THA. METHODS: A series of 379 acetabular revision THAs performed from January 2010 through August 2022 was retrospectively reviewed. Preoperative, perioperative, and postoperative factors were summarized for all revisions and compared between direct anterior and posterior revision THA. RESULTS: The average time to acetabular revision THA was 10 years (range, 0.04 to 44.1), with mechanical failure (36.7%) and metallosis (25.6%) being the most prevalent reasons for revision. No differences in age, body mass index, or sex were noted between groups. Anterior revision patients had a significantly shorter length of stay (2.2 versus 3.2 days, P = .003) and rate of discharge to a skilled nursing facility (7.5 versus 25.2%, P = .008). In the 90-day postoperative period, 9.2% of patients returned to the emergency department (n = 35) and twelve patients (3.2%) experienced a dislocation. There were 13.2% (n = 50) of patients having a rerevision during the follow-up period with a significant difference between anterior and posterior approaches (3.8 versus 14.7%, respectively, P = .049). CONCLUSION: This study provides some evidence that the anterior approach may be protective against skilled nursing facility discharge and rerevision and contributes to decreased lengths of stay. We recommend surgeons select the surgical approach for revision THA based on clinical preferences and patient factors.

Preoperative Education for Total Joint Arthroplasty: Does Reimbursement Reduction Threaten Improved Outcomes?

BACKGROUND: Nurse navigation programs have been previously shown to reduce cost and improve outcomes after total joint arthroplasty (TJA). Medicare has proposed a 13.7% reduction in professional fee reimbursement for TJA procedures that may adversely impact providers' and health systems' ability to fund ancillary support resources such as nurse navigators. METHODS: A consecutive series of primary TJAs performed between April 2019 and February 2020 was retrospectively reviewed. Clinical and financial outcomes of patients attending a nurse navigator-led preoperative education class were compared with those who did not attend. RESULTS: There were 2057 TJAs identified during the study period. Most patients attended the preoperative education class (82.7%) and were discharged home (92.8%). Controlling for significant differences between groups, class attendance was associated with reduced length of stay (LOS), increased chance of 0- or 1-day LOS, reduced chance of discharge to a skilled nursing facility, and reduced hospital charges. For this patient sample, a proposed 13.7% reduction in nurse navigator-led classes was modeled to increase overall cost to payers by >$400,000 annually. Complete elimination of this class was estimated to increase the total annual cost by >$5,700,000 and cost per TJA by >$2700. CONCLUSION: The use of a nurse navigator-led preoperative education class was associated with shorter LOS, more frequent 0- and 1-day LOS, reduced discharge to skilled nursing facilities, and lower total hospital charges for those patients who attended. Potential reductions proposed by Medicare may interfere with the ability to support such services and negatively impact both clinical and financial outcomes.

Reasons for Revision: Primary Total Hip Arthroplasty Mechanisms of Failure.

BACKGROUND: This study aimed to examine the major reasons for total hip arthroplasty (THA) failure and temporal patterns in THA revisions. METHODS: A retrospective chart review was conducted on 535 revisions performed on 444 THAs from January 2010 to May 2019 at our institution. RESULTS: The average time to revision THA was 8.51 ± 8.38 years, with 136 cases (30.9%) occurring within 2 years after primary THA. The major mechanisms of failure that resulted in revision surgery were mechanical failure (162, 36.5%), metallosis (95, 21.4%), dislocation or instability (65, 14.6%), periprosthetic fracture (46, 10.4%), infection (44, 9.9%), hematoma or poor wound healing (15, 3.4%), and pain or other (17, 3.8%). CONCLUSION: Based on our institutional experience over the past decade, mechanical failure without dislocation, metallosis, dislocation, periprosthetic fracture, and infection are typical reasons patients present for primary THA revision. Revisions within 2 years after primary THA are more likely to be the result of infection and periprosthetic fracture. Mechanical failure is the most common reason for revision THA overall, and mechanical failure and metallosis are more likely to be the reason revision is necessary 2 or more years after primary THA.

Same-Day vs One-Day Discharge: Rates and Reasons for Emergency Department Return After Hospital-Based Total Joint Arthroplasty.

BACKGROUND: As short stay and outpatient total joint arthroplasties (TJAs) are more widely adopted, it is important to assess whether reducing length of stay leads to increased emergency department (ED) visits or readmissions. METHODS: This is a retrospective review of 1743 primary TJA patients with same-day discharge (SDD) or 1-day length of stay between January and December 2019. Patients who returned to the ED or were readmitted within 30 days of TJA were identified, and chart review was performed to identify their primary reason for revisit. RESULTS: Patients discharged on the day of surgery (n = 203, 11.6%) were more likely to be younger (P < .001) and have a lower body mass index (total hip arthroplasty, P = .018; total knee arthroplasty, P < .001) and American Society of Anesthesiologists score (P < .001). The overall rate of return was 6.3%, and 1.3% of patients were readmitted. Controlling for age, gender, body mass index, surgery type, and American Society of Anesthesiologists, patients selected for SDD were not found to be at higher risk of return to the ED compared to 1-day length of stay patients (4.9% vs 6.4%, odds ratio 0.980, 95% confidence interval 0.484-1.984, P = .956). CONCLUSION: SDD of eligible patients does not increase the risk of 30-day return to the ED. Continued analysis of risk factors for return and readmission will improve prospective identification of patients who can safely be discharged on the day of surgery, and future quality improvement initiatives should target the most common reasons for ED return.

The Impact of Patient-Reported Penicillin Allergy on Risk for Surgical Site Infection in Total Joint Arthroplasty.

BACKGROUND: Penicillin (PCN) allergy is reported in 10% to 20% of the population; studies show that only 1% to 3% of patients have a true allergy. Most patients reporting a PCN allergy receive second-line antibiotic prophylaxis preoperatively, which raises concerns about antimicrobial efficacy. Studies also suggest that second-line antibiotics may increase the rate of surgical site infection (SSI). In this study we aim to analyze the effect of PCN allergy on antibiotic type prescribed and SSI in our total joint arthroplasty population. METHODS: A retrospective review of 4,903 primary total hip and total knee arthroplasty performed from January 2015 to June 2017 in a single institution. A detailed chart review was performed to identify reported reactions and antibiotic prescribed. RESULTS: Seven hundred ninety-six patients (16.2%) reported a PCN allergy; the reactions were classified into three tiers. Six hundred fifteen patients (12.5%) reported an IgE-mediated allergy, hypersensitivity, or a possible allergy; 89 (1.8%) reported an adverse effect; and 92 (1.9%) had an unknown reaction. Patients reporting a PCN allergy were less likely to receive cefazolin (94.9 versus 6.9%; P < 0.001) and more likely to receive clindamycin (1.1 versus 80.7%; P < 0.001) or vancomycin (4.0 versus 12.4%; P < 0.001). There was no difference in infection rate by reported PCN allergy (0.6 versus 0.4%; P = 0.473) or antibiotic prescribed (0.5 versus 0.6%; P = 0.4817). CONCLUSION: No patient with a PCN allergy and given cefazolin experienced a reaction; based on reported reactions, most patients with a PCN allergy can safely receive first-line antibiotic therapy. In this population, PCN allergy and second-line antibiotic therapy did not influence the rate of SSI.