Efficacy of Liposomal Bupivacaine Infiltration on the Management of Total Knee Arthroplasty.

Importance: Liposomal bupivacaine is a novel extended-duration anesthetic that has recently been used for local infiltration in total knee arthroplasty (TKA). Athough liposomal bupivacaine is widely used, it is unknown if the benefits justify the cost in the veteran population at our institution. Objective: To evaluate a change in practice: the effect of local infiltration of liposomal bupivacaine on perioperative outcomes in patients undergoing primary TKA. Design, Setting, and Participants: A retrospective cohort study was conducted among patients who underwent primary TKA at a Veterans Affairs Medical Center before (March 3, 2013-March 2, 2014) and after (March 3, 2014-March 2, 2015) the implementation of liposomal bupivacaine for local infiltration in TKA. Intervention: Drug utilization evaluation of liposomal bupivacaine for local infiltration in TKA. Main Outcomes and Measures: Use of opioids after discharge from the postanesthesia care unit. Results: Among 199 patients, those who received liposomal bupivacaine after primary TKA (mean [SD] age, 65.3 [6.9] years; 93 males and 5 females) had a reduced median opioid use in the first 24 hours after surgery compared with those who did not receive liposomal bupivacaine (mean [SD] age, 64.9 [8.4] years; 95 males and 6 females; [intravenous morphine equivalents, 12.50 vs 22.50 mg; P = .001]). The use of patient-controlled analgesia was also reduced among patients who received liposomal bupivacaine vs those who did not (49 vs 91; P < .001). A reduction in the use of antiemetics was observed in the first 24 hours after surgery (13 vs 34; P = .001) and in the postanesthesia care unit among those who received liposomal bupivacaine vs those who did not (4 vs 20; P = .001). The number of patients in the postanesthesia care unit with no pain was improved among those who received liposomal bupivacaine vs those who did not (44 vs 19; P < .001). Although median (interquartile range) pain scores in the postanesthesia care unit were improved among patients who received liposomal bupivacaine vs those who did not (4.0 [0.0-6.6] vs 5.5 [3.0-7.5]; P = .001), patients who received liposomal bupivacaine had greater median (interquartile range) pain scores 48 hours (5.5 [4.0-7.0] vs 5.0 [3.0-6.0]; P = .01), 72 hours (5.0 [4.0-6.0] vs 4.0 [2.0-6.0]; P = .002), and 96 hours (5.0 [3.0-6.5] vs 4.0 [1.0-5.0]; P = .003) after surgery than those who did not receive liposomal bupivacaine. There was no difference in the median length of stay between the 2 groups. Institutional cost savings was estimated at $27 000 per year. Conclusions and Relevance: Local infiltration of liposomal bupivacaine reduces use of opioids in the first 24 hours after primary TKA. Similarly, reduction in antiemetic use and improved postoperative pain are also seen in the first 24 hours after surgery but are limited to this time frame. Furthermore, a positive institutional cost savings was observed.

Long-term outcome of surface replacement with comparison to an age- and time-matched primary total hip arthroplasty cohort.

Surface replacement (SR) was introduced as a bone-conserving alternative to total hip arthroplasty (THA) 3 decades ago, then was abandoned due to polyethylene wear, stress shielding, and loosening. Improved bearing surfaces have renewed interest in SR. This study examined long-term SR outcome compared to an age- and time-matched THA cohort. Average age was 47 years at index procedure with 16 years follow-up (range, 5-28). Revision rates were 86% and 40% in SR and THA groups, respectively. However, at 20 years, with an end point of either intact SR or primary THA in the SR group, survivorship was 64% +/- 6% versus 39% +/- 7% unrevised in THA cohort. Contemporary and rapidly changing technology may result in longer-term SR success and improved THA longevity in young patients.

Does smoking affect implant survivorship in total hip arthroplasty? A preliminary retrospective case series.

This retrospective study aimed to explore the effects of smoking on hip implant survivorship. The study included 147 patients (165 hips) from 1985 to 1991 who underwent total hip arthroplasty (THA) with a particular uncemented cup, and either a cemented or uncemented femoral component of the same design. Thirty-one patients (34 hips, 21 percent of study group) smoked at the time of surgery. Of 13 components (seven cups, five cemented and one cementless stem) revised for aseptic loosening, eight (8/68, 11.8 percent) were revised in six smokers, and five (5/262, 1.9 percent) were revised in four nonsmokers (p = 0.0012). Multivariate covariate analysis revealed a 4.5 times greater risk of implant loosening in smokers (p = 0.0662). Based on this preliminary study, further larger studies should be performed to determine the extent that smoking may contribute to THA survivorship.

Pilot study of the effects of a heat-retaining knee sleeve on joint pain, stiffness, and function in patients with knee osteoarthritis.

OBJECTIVE: To identify changes in joint pain, stiffness, and functional ability in patients with knee osteoarthritis (OA) after use of a knee sleeve that prevents loss of body heat by the joint. METHODS: Subjects with symptomatic knee OA (n = 52) were randomized to 2 treatment groups: verum sleeve (specially fabricated to retain body heat) or placebo sleeve (standard cotton/elastane sleeve). Subjects wore the sleeve over the more painful OA knee for at least 12 hours daily for 4 weeks. Pain, stiffness, and functional impairment (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) in the index knee were measured at baseline and after 4 weeks of wear, after which sleeve use was discontinued. Telephone followup interviews were conducted 2 and 4 weeks later. RESULTS: After 4 weeks of sleeve wear, subjects in the active treatment group reported a 16% decrease in mean WOMAC pain score relative to baseline (P = 0.001). Those who wore the placebo sleeve reported a 9.7% decrease from baseline (P = 0.002). The difference between treatment groups was not statistically significant (P = 0.12). However, it was found that the 12 subjects who believed correctly that they had received the verum sleeve reported a highly significant decrease in WOMAC pain score (-27.5% relative to baseline, P = 0.0001). In comparison, subjects who received the verum sleeve but believed they had received the placebo sleeve exhibited only a marginally significant improvement in pain (-13.0% relative to baseline, P = 0.07). In the placebo group, the modest improvement in pain scores appeared unrelated to the subject's impression of the type of sleeve worn. CONCLUSION: This pilot study was insufficiently powered to be a definitive trial of the heat-retaining sleeve. Given the magnitude of changes in knee pain in the active treatment group, heat retention merits further scientific investigation as a treatment modality for patients with knee OA.

Septic arthritis of the ankle due to Salmonella enteritidis: a case report.

Salmonella septic arthritis in healthy individuals is a rare phenomenon in the United States. This case report chronicles the clinical course of a 41-year-old male farmworker who presented with a 3-week history of fever, chills, night sweats with pain, and swelling and redness of his left ankle. He had an open fracture of the ankle 2 years earlier that healed and was asymptomatic despite prior radiographic evidence of avascular necrosis of the talar dome. One month before presentation, he had an ipsilateral periungual abscess of the great toe that he opened and drained himself. Joint cultures were positive for Salmonella enteritidis that was successfully treated with a 6-week course of i.v. ceftriaxone.

Clinical outcome and incidence of pregnancy after bipolar and total hip arthroplasty in young women.

Female patients under 45 years of age (average, 32.5; range, 14-44) at the time of primary bipolar or total hip arthroplasty (THA) were surveyed an average 10.5 years (range, 1.7 to 20.3 years) after the index procedure. Most patients were satisfied with the pain relief and functional abilities. Of the 109 respondents (137 hips), 37 (34%) had undergone 50 additional hip procedures. Thirteen women (12%) had 19 children at an average of 3 years after hip arthroplasty. Seven women had 1 child each; 6 had 2 children; and 1 had dizygotic twins. Eleven infants were delivered vaginally and 8 by cesarean section (5 planned, 3 unplanned). Two pregnancies were considered high risk unrelated to the hip arthroplasty. Pregnancy-related complications for these patients did not differ from those in the general population.

An assessment of the biological fixation of a retrieved Mayo femoral component.

Implant analysis was conducted on a retrieved Mayo femoral prosthesis that has a non-anatomic design with two distinct surfaces intended for osseous fixation. The prosthesis itself has a circumferential grit-blasted region interposed with the porous surfaces and involving the entire proximal stem. In addition, there are pads of mesh porous coating on the anterior, posterior, and medial surfaces proximally. A single, radiographically stable stem retrieved after 18 months secondary to recurrent dislocations was examined for osseous fixation by measurement of trabecular bone into the porous-coated and onto the grit-blasted surfaces of the stem. Results showed 17% +/- 7% bone ingrowth into the porous coated areas and 20% +/- 16% osseointegration onto the grit-blasted surfaces. These results are similar to percentages of ingrowth seen with more conventional, anatomic design prostheses.

Elective primary total hip arthroplasty in octogenarians.

BACKGROUND: Total hip arthroplasty (THA) has resulted in decreased pain and increased function in people with end-stage hip arthritis for several decades. In elderly people, THA has been used most often following femoral neck fracture. However, with life spans increasing and people remaining healthy and active well into their eighties, arthroplasty surgeons are now performing primary THA as an elective procedure in octogenarians. The aim of this study was to demonstrate the efficacy of elective total hip arthroplasty in patients aged 80 years or older with end-stage hip arthritis. METHODS: Forty patients (46 THAs), aged 80 or older at the time of surgery, were identified for this study. Clinical assessment included amount of hip pain, limp, and use of assistive devices for ambulation at most recent follow-up. Radiographic assessment included implant stability, heterotopic bone formation, and osteolysis. Medical and hip-related complications, reoperations, and revisions were recorded from medical records. RESULTS: Eleven patients (27.5%) suffered a medical complication and six patients (15%) had a hip-related complication, all of which were treated and were not life threatening. Clinically, 80% were pain free and 70% walked without assistance at an average 4-year follow-up. Radiographically, all implants were stable without osteolysis. No components had been revised; however, four patients had undergone a reoperation, three for recurrent dislocation. CONCLUSIONS: Elective total hip arthroplasty is a safe and effective treatment for end-stage osteoarthritis of the hip in the elderly patient. However, the procedure is not without risk. Complications, often related to preexisting comorbidities, do occur, but mortality rates are low.

Compartment syndrome of the leg after less than 4 hours of elevation on a fracture table.

Compartment syndrome of the leg is usually associated with significant trauma. It has also been associated with prolonged surgery in the hemilithotomy position. Fracture tables that are used for the internal fixation of proximal femur fractures under fluoroscopy place a patient in this position. This report chronicles two cases of intraoperative compartment syndrome of the leg that was elevated and contralateral to a subtrochanteric femoral fracture. In each case, the syndrome was found at the procedure's conclusion and was addressed with fasciotomies. One patient continued to have neurologic sequelae from the compartment syndrome 2 years later.