Revision total knee arthroplasty with porous-coated metaphyseal sleeves provides radiographic ingrowth and stable fixation.

PURPOSE: Porous-coated metaphyseal sleeves are designed to fill bone defects and facilitate osseointegration when bone loss in encountered during revision total knee arthroplasty (TKA). The purpose of this study is to evaluate short-term results of porous-coated metaphyseal sleeves with regards to implant fixation and clinical outcomes. METHODS: A retrospective review was conducted on 50 patients (79 sleeves-49 tibial and 30 femoral) who had a press-fit metaphyseal sleeve with revision TKA. Tibial and femoral bone loss was classified according to the Anderson Orthopaedic Research Institute (AORI) bone defect classification. Post-operative complications of infection, revision surgery, and dislocation were assessed. Follow-up radiographs were evaluated for signs of loosening using the criteria developed by the Knee Society. The median follow-up was 58.8 months (range 25.8-93.0 months). RESULTS: The bone loss classifications were 1 type 1, 30 type 2a, 2 type 2b, and 17 type 3, and with regards to the femur, 5 were type 1, 8 type 2a, 31 type 2b, and 6 type 3. At final follow-up, 41/45 (91.1%) tibial and 28/29 (96.6%) femoral sleeves showed radiographic evidence of ingrowth. Of these 69 patients, all showed radiographic evidence of bony ingrowth. Three sleeves were revised for infection and two for loosening. The re-operation rate for loosening was 5/74 (6.8%) and for any reason was 14/74 (18.9%). CONCLUSIONS: Modular porous-coated press fit metaphyseal sleeves fill defects and provide evidence of radiographic ingrowth. Short-term stable fixation can be achieved with sleeves, which is helpful as more patients undergo revision total knee arthroplasty with greater bone loss. Longer duration studies are needed to ascertain the survival rate of these implants. LEVEL OF EVIDENCE: IV.

Radiographic features associated with differing impinging hip morphologies with special attention to coxa profunda.

BACKGROUND: Combined with clinical examination and MRI, radiographs have been mainstays in the management femoroacetabular impingement (FAI). Because hip morphology often portends intraoperative damage, radiographic features should inform surgical management. QUESTIONS/PURPOSES: We determined (1) the radiographic features of the various hip morphologies; (2) the prevalence of radiographic coxa profunda in each group; (3) the radiographic differences between hips with and without coxa profunda; and (4) its sensitivity and specificity as a measure of global acetabular overcoverage. METHODS: We reviewed preoperative radiographs and operative notes of 144 hips that underwent surgical dislocation and correction for FAI between August 2002 and February 2011. Hips were divided into four FAI subtypes by radiographic analysis (cam, global overcoverage, retroversion, and combined) and three subtypes (cam, pincer, or combined) by intraarticular pathology. Standard radiographic measurements were performed, and we introduce a novel measurement that assesses femoral head coverage. RESULTS: We found differences in median Angle of Sharp, femoral head-neck angle, and median roof length (and its subset) among the FAI morphologies. The prevalence of radiographic coxa profunda was 48% in cam hips, 85% in global overcoverage hips, 66% in retroverted hips, and 32% in combined hips. The sensitivity and specificity of radiographic coxa profunda as a measure of global overcoverage was 75% (95% CI, 0.62-0.85) and 62% (95% CI, 0.51-0.73), respectively. CONCLUSIONS: We found major differences in radiographic measurements between FAI morphologies. Radiographic coxa profunda was poorly specific for global overcoverage. Measurement of roof length and ratio should be used to determine the morphology of the impinging hip. LEVEL OF EVIDENCE: Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Multimodal pain management with peripheral nerve blocks for total knee arthroplasty.

Multimodal pain management techniques using femoral and sciatic nerve blocks can dramatically improve a patient's experience after total knee arthroplasty. Nerve blocks reduce postoperative pain and the need for parenteral opioids and result in fewer medical complications associated with opioid use. Peripheral nerve blocks have traditionally been underutilized in lower extremity surgery; however, more modern techniques now allow for safe, efficient, and reliable femoral and sciatic blocks. Peripheral nerve blocks are now routinely used in both primary and revision total knee arthroplasty. Although it is difficult to isolate the added benefit of sciatic nerve blocks, there is a growing body of evidence for using femoral and/or sciatic nerve blocks as part of a multimodal approach to pain management. With many years of experience and published results on thousands of patients, it is clear that the risks of peripheral nerve blocks are minimal, whereas the benefits are substantial.

Displaced femoral neck fractures in the elderly: hemiarthroplasty versus total hip arthroplasty.

The incidence of femoral neck fracture among the elderly in the United States is expected to increase dramatically because of the anticipated explosion in the population aged 65 years and older, increased life expectancy, and the rising incidence of osteoporosis. The resulting public health implications may be significant, with annual hospital admissions resulting from hip fracture projected to increase to 700,000 by 2050, and with annual spending on hip fracture care expected to exceed 15 billion dollars within a few years. The decision to perform internal fixation, unipolar hemiarthroplasty, bipolar hemiarthroplasty, or THA must be based on patient mental status, living arrangement, level of independence and activity, and bone and joint quality.